Provider Demographics
NPI:1497938849
Name:AYOOLA-YUSSUF, EBUNOLA M (PMHNP)
Entity Type:Individual
Prefix:
First Name:EBUNOLA
Middle Name:M
Last Name:AYOOLA-YUSSUF
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 HARBOR CENTER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2847
Mailing Address - Country:US
Mailing Address - Phone:703-977-6556
Mailing Address - Fax:703-997-1490
Practice Address - Street 1:13000 HARBOR CENTER DR STE 103
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2847
Practice Address - Country:US
Practice Address - Phone:703-977-6556
Practice Address - Fax:703-997-1490
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-07
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182859363LP0808X
VA0001244167163W00000X
NY289579164W00000X
NY624955-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024182859OtherPSYCHIATRIC NURSE PRACTITIONER