Healthcare Provider Details

I. General information

NPI: 1306697057
Provider Name (Legal Business Name): PAULINE FAGBUYI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 BRYAN PL SE
WASHINGTON DC
20020-4417
US

IV. Provider business mailing address

2600 BRYAN PL SE
WASHINGTON DC
20020-4417
US

V. Phone/Fax

Practice location:
  • Phone: 202-423-7604
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR127660
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: