Provider Demographics
NPI:1356841514
Name:IKETUBOSIN, ABIMBOLA DATONYE (FNP)
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:DATONYE
Last Name:IKETUBOSIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:
Practice Address - Street 1:15351 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4580
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011284163WG0000X, 363LF0000X
AZF08180855363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP11576FMedicaid