Provider Demographics
NPI:1346928454
Name:ADEGBOLA, BUKOLA
Entity Type:Individual
Prefix:
First Name:BUKOLA
Middle Name:
Last Name:ADEGBOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 WHITETAIL DEER LN
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-7066
Mailing Address - Country:US
Mailing Address - Phone:919-798-3988
Mailing Address - Fax:
Practice Address - Street 1:1399 ASHLEYBROOK LN STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2961
Practice Address - Country:US
Practice Address - Phone:336-774-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003225364SP0808X
NC5018600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health