Provider Demographics
NPI:1982086344
Name:OLUSOLA IGE, AJISOLA
Entity Type:Individual
Prefix:
First Name:AJISOLA
Middle Name:
Last Name:OLUSOLA IGE
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 1:383 E 162ND ST
Mailing Address - Street 2:10A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-4595
Mailing Address - Country:US
Mailing Address - Phone:347-854-5822
Mailing Address - Fax:
Practice Address - Street 1:383 E 162ND ST
Practice Address - Street 2:10A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-4595
Practice Address - Country:US
Practice Address - Phone:347-854-5822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322059-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse