Healthcare Provider Details

I. General information

NPI: 1881255842
Provider Name (Legal Business Name): FLORENCE O FAKAYODE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BALLENGER CENTER DR
FREDERICK MD
21703-7096
US

IV. Provider business mailing address

300 BALLENGER CENTER DR
FREDERICK MD
21703-7096
US

V. Phone/Fax

Practice location:
  • Phone: 301-682-7213
  • Fax:
Mailing address:
  • Phone: 301-682-7213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR169935
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: