Healthcare Provider Details

I. General information

NPI: 1992166193
Provider Name (Legal Business Name): HAKIM OGUNSANYA CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12001 MARGARET CT
MARRIOTTSVILLE MD
21104-1443
US

IV. Provider business mailing address

12001 MARGARET CT
MARRIOTTSVILLE MD
21104-1443
US

V. Phone/Fax

Practice location:
  • Phone: 301-906-7349
  • Fax:
Mailing address:
  • Phone: 301-906-7349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR184091
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: