Healthcare Provider Details

I. General information

NPI: 1962861955
Provider Name (Legal Business Name): YETUNDE OTUBANJO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 MOSS BANK DR
LAUREL MD
20724-2932
US

IV. Provider business mailing address

8001 MOSS BANK DR
LAUREL MD
20724-2932
US

V. Phone/Fax

Practice location:
  • Phone: 301-509-0739
  • Fax:
Mailing address:
  • Phone: 301-509-0739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR5052
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: