Healthcare Provider Details

I. General information

NPI: 1508324971
Provider Name (Legal Business Name): MARY OGUNLOWO-OMOBHUDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 CRAIN HWY S STE 3
GLEN BURNIE MD
21061-3657
US

IV. Provider business mailing address

4505 BLACKBIRDS FOLLY LN
BOWIE MD
20720-5803
US

V. Phone/Fax

Practice location:
  • Phone: 240-602-7035
  • Fax:
Mailing address:
  • Phone: 240-602-7035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1508324971
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: