Healthcare Provider Details

I. General information

NPI: 1215650619
Provider Name (Legal Business Name): OLUWASEUN MARY OGUNBAJO CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 04/19/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S PACA ST
BALTIMORE MD
21201-1642
US

IV. Provider business mailing address

110 S PACA ST
BALTIMORE MD
21201-1642
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6266
  • Fax: 410-328-0697
Mailing address:
  • Phone: 410-328-6266
  • Fax: 410-328-0697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR193854
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: