Provider Demographics
NPI:1114309283
Name:AJIMAVO, ANTHONIA (NP)
Entity type:Individual
Prefix:
First Name:ANTHONIA
Middle Name:
Last Name:AJIMAVO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-1199
Mailing Address - Country:US
Mailing Address - Phone:718-292-0100
Mailing Address - Fax:
Practice Address - Street 1:2604 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-1199
Practice Address - Country:US
Practice Address - Phone:718-292-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307288-1363LA2200X
NYF405705363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health