Healthcare Provider Details

I. General information

NPI: 1619428638
Provider Name (Legal Business Name): OLUWAFUNMBI FASINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4265 58TH AVE APT T1
BLADENSBURG MD
20710-1922
US

IV. Provider business mailing address

723 FARAWAY CT
BOWIE MD
20721-1824
US

V. Phone/Fax

Practice location:
  • Phone: 240-838-9392
  • Fax:
Mailing address:
  • Phone: 240-838-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA12346
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: