Healthcare Provider Details

I. General information

NPI: 1063061034
Provider Name (Legal Business Name): MODINAT OLUWATOYIN FAGBENRO PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 DAYLILY DR
OWINGS MILLS MD
21117-5034
US

IV. Provider business mailing address

4105 DAYLILY DR
OWINGS MILLS MD
21117-5034
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-4471
  • Fax:
Mailing address:
  • Phone: 410-800-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR210603
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: