Healthcare Provider Details

I. General information

NPI: 1700341856
Provider Name (Legal Business Name): QUEEN BISOLA O MUMUNEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ALABASTER CT
CAPITOL HEIGHTS MD
20743-1872
US

IV. Provider business mailing address

6180 SCAGGS RD
OWINGS MD
20736-4208
US

V. Phone/Fax

Practice location:
  • Phone: 301-442-5109
  • Fax:
Mailing address:
  • Phone: 301-442-5109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR175488
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR175488
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: