Healthcare Provider Details

I. General information

NPI: 1215558259
Provider Name (Legal Business Name): TAIWO LOLADE OGUNTIMEHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 K ST NE
WASHINGTON DC
20002-4216
US

IV. Provider business mailing address

10574 SOURWOOD AVE
WALDORF MD
20603-5711
US

V. Phone/Fax

Practice location:
  • Phone: 202-442-4202
  • Fax: 202-727-0855
Mailing address:
  • Phone: 240-565-7517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN1048174
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: