Healthcare Provider Details

I. General information

NPI: 1982170213
Provider Name (Legal Business Name): TAIWO OLUGBENGA AJANI DNP, CRNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2018
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9811 MALLARD DR STE 120
LAUREL MD
20708-3180
US

IV. Provider business mailing address

1900 E NORTHERN PKWY STE T7
BALTIMORE MD
21239-2120
US

V. Phone/Fax

Practice location:
  • Phone: 443-713-8643
  • Fax:
Mailing address:
  • Phone: 443-713-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN1002193
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR159659
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR159659
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: