Provider Demographics
NPI:1265830616
Name:BANJO, OLUBUNMI FUNMILAYO (NP)
Entity Type:Individual
Prefix:
First Name:OLUBUNMI
Middle Name:FUNMILAYO
Last Name:BANJO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9939 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3528
Mailing Address - Country:US
Mailing Address - Phone:951-687-8802
Mailing Address - Fax:951-687-2250
Practice Address - Street 1:10800 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3043
Practice Address - Country:US
Practice Address - Phone:213-249-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000540363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily