Healthcare Provider Details

I. General information

NPI: 1417558131
Provider Name (Legal Business Name): MRS. OLUBUNMI O AIYEGBUSI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 OLD SOUTH NORTHPOINT RD
BALTIMORE MD
21224
US

IV. Provider business mailing address

1046 OLD NORTHPOINT RD
BALTIMORE MD
21224
US

V. Phone/Fax

Practice location:
  • Phone: 410-282-0100
  • Fax: 410-284-5693
Mailing address:
  • Phone: 410-282-0100
  • Fax: 410-284-5693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR616210
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR212610
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: