Provider Demographics
NPI:1669280293
Name:IYIOLA, BOLUWAJI
Entity type:Individual
Prefix:
First Name:BOLUWAJI
Middle Name:
Last Name:IYIOLA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 RADLEY CT
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-9179
Mailing Address - Country:US
Mailing Address - Phone:309-203-6902
Mailing Address - Fax:
Practice Address - Street 1:4102 SHORE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2608
Practice Address - Country:US
Practice Address - Phone:317-597-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71016263A363LP0808X, 363LP0808X
IN28284335A163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health