Healthcare Provider Details

I. General information

NPI: 1629794821
Provider Name (Legal Business Name): OLUWABUSUYI OGUNSOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MERCANTILE LN
LARGO MD
20774-5374
US

IV. Provider business mailing address

1221 MERCANTILE LN
UPPER MARLBORO MD
20774-5374
US

V. Phone/Fax

Practice location:
  • Phone: 310-386-6775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number195073
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: