Provider Demographics
NPI:1518619444
Name:AJALA, MOSUNMOLUWA PRAISE
Entity Type:Individual
Prefix:
First Name:MOSUNMOLUWA
Middle Name:PRAISE
Last Name:AJALA
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 1:550 WRENHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6232
Mailing Address - Country:US
Mailing Address - Phone:470-699-6332
Mailing Address - Fax:
Practice Address - Street 1:550 WRENHAVEN CT
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6232
Practice Address - Country:US
Practice Address - Phone:470-699-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030054436376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide