Healthcare Provider Details

I. General information

NPI: 1407524457
Provider Name (Legal Business Name): DEIDRA OGBUANYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10440 LITTLE PATUXENT PKWY STE 800
COLUMBIA MD
21044-3569
US

IV. Provider business mailing address

10440 LITTLE PATUXENT PKWY STE 800
COLUMBIA MD
21044-3569
US

V. Phone/Fax

Practice location:
  • Phone: 908-344-0844
  • Fax:
Mailing address:
  • Phone: 908-344-0844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001304999
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: