Healthcare Provider Details

I. General information

NPI: 1306291752
Provider Name (Legal Business Name): AUTUMN WILLOW OGUNBAMISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN WILLOW CROFUT NP

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-0916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1022958
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: