Healthcare Provider Details

I. General information

NPI: 1952136178
Provider Name (Legal Business Name): MODUPE ANTHONY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 LA GRANGE AVE
LA PLATA MD
20646-0198
US

IV. Provider business mailing address

118 LA GRANGE AVE
LA PLATA MD
20646-0198
US

V. Phone/Fax

Practice location:
  • Phone: 240-349-2536
  • Fax: 800-517-4345
Mailing address:
  • Phone: 240-349-2536
  • Fax: 800-517-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR219754
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: