Provider Demographics
NPI:1639897788
Name:IPPOLITO, AYODELE C
Entity Type:Individual
Prefix:
First Name:AYODELE
Middle Name:C
Last Name:IPPOLITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AYODELE
Other - Middle Name:C
Other - Last Name:IFAFORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 CRITTENDEN BLVD BOX PSYCH
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-276-8375
Mailing Address - Fax:
Practice Address - Street 1:2613 W HENRIETTA RD STE B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2327
Practice Address - Country:US
Practice Address - Phone:585-279-4999
Practice Address - Fax:585-473-5152
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029370363A00000X
NY29370363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical