Provider Demographics
NPI:1700599792
Name:OLUBAMBO, ADEYEMI
Entity Type:Individual
Prefix:
First Name:ADEYEMI
Middle Name:
Last Name:OLUBAMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3204
Mailing Address - Country:US
Mailing Address - Phone:480-938-8232
Mailing Address - Fax:
Practice Address - Street 1:661 W 10TH ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3204
Practice Address - Country:US
Practice Address - Phone:480-938-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN210315163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty