Provider Demographics
NPI:1275709792
Name:ADEBIYI, ADENIKE ADEMIBOWALE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ADENIKE
Middle Name:ADEMIBOWALE
Last Name:ADEBIYI
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 DEER HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-8901
Mailing Address - Country:US
Mailing Address - Phone:920-203-6196
Mailing Address - Fax:
Practice Address - Street 1:1217 DEER HAVEN DR
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-8901
Practice Address - Country:US
Practice Address - Phone:920-203-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI135828-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38233500Medicaid