Healthcare Provider Details

I. General information

NPI: 1285126912
Provider Name (Legal Business Name): TITILAYO ADENIKE UNEGBU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 CROSS CHURCH WAY
MITCHELLVILLE MD
20721-2398
US

IV. Provider business mailing address

13106 CONTEE MANOR RD
BOWIE MD
20721-3299
US

V. Phone/Fax

Practice location:
  • Phone: 410-440-8763
  • Fax:
Mailing address:
  • Phone: 410-440-8763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2022091446
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberMDR117409
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: