MEDICARE: MODINAT OLUWATOYIN FAGBENRO PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	R210603	MD

General Provider Information

NPI Number	:	1063061034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MODINAT OLUWATOYIN FAGBENRO PMHNP-BC

Provider Business Mailing Address
First Line	:	4105 DAYLILY DR
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-5034
Country	:	US
Telephone Number	:	410-800-4471
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 W PADONIA RD STE C252
Second Line	:
City	:	LUTHERVILLE TIMONIUM
State	:	MD
Zip	:	21093-2241
Country	:	US
Telephone Number	:	410-768-6088
Fax Number	:	410-768-6444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2019
Last Update Date	:	01/20/2026

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