Healthcare Provider Details

I. General information

NPI: 1629439948
Provider Name (Legal Business Name): OLUKEMI B OGUNMAKINWA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18566 OFFICE PARK DR
MONTGOMERY VILLAGE MD
20886-0587
US

IV. Provider business mailing address

18566 OFFICE PARK DR
MONTGOMERY VILLAGE MD
20886-0587
US

V. Phone/Fax

Practice location:
  • Phone: 301-769-6640
  • Fax:
Mailing address:
  • Phone: 301-769-6640
  • Fax: 301-769-6640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR159264
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: