Provider Demographics
NPI:1689920365
Name:ADENIJI-ILESANMI, GRACE TEMITOPE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:TEMITOPE
Last Name:ADENIJI-ILESANMI
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 1:6170 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1892
Mailing Address - Country:US
Mailing Address - Phone:423-643-0758
Mailing Address - Fax:
Practice Address - Street 1:2021 HAMILTON PLACE BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6046
Practice Address - Country:US
Practice Address - Phone:423-899-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily