Provider Demographics
NPI:1205564242
Name:ELELU, RICHARD NASIRU
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:NASIRU
Last Name:ELELU
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 1:7125 EAST CESAR CHAVEZ BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349-0376
Mailing Address - Country:US
Mailing Address - Phone:928-627-8871
Mailing Address - Fax:
Practice Address - Street 1:7125 EAST CESAR CHAVEZ BOULEVARD
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-0376
Practice Address - Country:US
Practice Address - Phone:928-627-8871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ278312363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health