Healthcare Provider Details

I. General information

NPI: 1316239171
Provider Name (Legal Business Name): EDITH OGUNSANYA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8713 MULBERRY ST
LAUREL MD
20707-4916
US

IV. Provider business mailing address

8713 MULBERRY ST
LAUREL MD
20707-4916
US

V. Phone/Fax

Practice location:
  • Phone: 301-362-1117
  • Fax:
Mailing address:
  • Phone: 240-429-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR174346
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR174346
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR174346
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: