Healthcare Provider Details

I. General information

NPI: 1023667557
Provider Name (Legal Business Name): OLUSEYI IGE OGUNDANA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2019
Last Update Date: 09/10/2023
Certification Date: 09/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 PARK HEIGHTS AVE
BALTIMORE MD
21215-6331
US

IV. Provider business mailing address

800 INGLESIDE AVE STE C1
CATONSVILLE MD
21228-1796
US

V. Phone/Fax

Practice location:
  • Phone: 240-413-5721
  • Fax:
Mailing address:
  • Phone: 240-413-5721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR223394
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: