Healthcare Provider Details

I. General information

NPI: 1972327617
Provider Name (Legal Business Name): OLUWAKEMI FAGBUYI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4623 MORNING GLORY TRL
BOWIE MD
20720-4264
US

IV. Provider business mailing address

4623 MORNING GLORY TRL
BOWIE MD
20720-4264
US

V. Phone/Fax

Practice location:
  • Phone: 202-487-9587
  • Fax:
Mailing address:
  • Phone: 202-487-9587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR239812
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: