Healthcare Provider Details

I. General information

NPI: 1770038374
Provider Name (Legal Business Name): TITILAYO OTUNUGA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 MARLBORO PIKE
DISTRICT HEIGHTS MD
20747-2841
US

IV. Provider business mailing address

7313 BRECKENRIDGE ST
LAUREL MD
20707-6935
US

V. Phone/Fax

Practice location:
  • Phone: 301-736-7000
  • Fax:
Mailing address:
  • Phone: 301-256-4643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR167309
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: