Healthcare Provider Details

I. General information

NPI: 1770312472
Provider Name (Legal Business Name): OLUWATOBI ADETULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13121 BROOKLANE DR
HAGERSTOWN MD
21742-1514
US

IV. Provider business mailing address

516 S CONKLING ST
BALTIMORE MD
21224-4201
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-0330
  • Fax:
Mailing address:
  • Phone: 301-679-0910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR252976
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number926378
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: