Healthcare Provider Details

I. General information

NPI: 1861921900
Provider Name (Legal Business Name): BOLA T MOBOLAJI CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2017
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 GRAND CENTRAL AVE
OWINGS MILLS MD
21117-3994
US

IV. Provider business mailing address

10201 GRAND CENTRAL AVE
OWINGS MILLS MD
21117-3994
US

V. Phone/Fax

Practice location:
  • Phone: 860-371-7067
  • Fax:
Mailing address:
  • Phone: 860-371-7067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberSP017427
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP023111
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: