Healthcare Provider Details

I. General information

NPI: 1699686501
Provider Name (Legal Business Name): OMONIYI AWE CPRP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 OLD ORCHARD RD
BALTIMORE MD
21229-2440
US

IV. Provider business mailing address

410 OLD ORCHARD RD
BALTIMORE MD
21229-2440
US

V. Phone/Fax

Practice location:
  • Phone: 443-703-8301
  • Fax:
Mailing address:
  • Phone: 443-703-8301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number81724492
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: