Healthcare Provider Details

I. General information

NPI: 1952860660
Provider Name (Legal Business Name): MODUPE FADOJUTIMI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAGNOLIA DR
LA PLATA MD
20646-9357
US

IV. Provider business mailing address

1 MAGNOLIA DR
LA PLATA MD
20646-9357
US

V. Phone/Fax

Practice location:
  • Phone: 301-934-4001
  • Fax:
Mailing address:
  • Phone: 301-934-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR194540
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: