Provider Demographics
NPI:1790363653
Name:AJAO, SHIYANBOLA
Entity type:Individual
Prefix:
First Name:SHIYANBOLA
Middle Name:
Last Name:AJAO
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 1:1800 PHOENIX BLVD STE 128-12
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5593
Mailing Address - Country:US
Mailing Address - Phone:678-525-7787
Mailing Address - Fax:
Practice Address - Street 1:540 NORTH AVE # 2036
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7148
Practice Address - Country:US
Practice Address - Phone:912-844-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10009869363LP0808X
WAAP61395314363LP0808X
GARN263471363LP0808X, 163W00000X
NJ26NJ14933300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse