Basic Information
| Provider Information | |||||||||
| NPI: | 1356841514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IKETUBOSIN | ||||||||
| FirstName: | ABIMBOLA | ||||||||
| MiddleName: | DATONYE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 N CENTRAL AVE STE 145 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235833001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15351 W BELL RD | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853744580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2018 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 95011284 | CA | N | Nursing Service Providers | Registered Nurse | General Practice | 363LF0000X | F08180855 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 95011284 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.