Healthcare Provider Details

I. General information

NPI: 1164758603
Provider Name (Legal Business Name): ELIZABETH IRE OLUMESE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2009
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7375 EXECUTIVE PL STE 400
LANHAM MD
20706-6232
US

IV. Provider business mailing address

7375 EXECUTIVE PL STE 400
LANHAM MD
20706-6232
US

V. Phone/Fax

Practice location:
  • Phone: 202-723-4392
  • Fax:
Mailing address:
  • Phone: 202-723-4392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN65222
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR131054
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: