Healthcare Provider Details

I. General information

NPI: 1073491106
Provider Name (Legal Business Name): OMOLOLA OLUWASEUN OGUNGBILE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 APPLE VALLEY DR
PASADENA MD
21122-4174
US

IV. Provider business mailing address

7736 ROTHERHAM DR
HANOVER MD
21076-1460
US

V. Phone/Fax

Practice location:
  • Phone: 410-841-9998
  • Fax:
Mailing address:
  • Phone: 410-841-9998
  • Fax: 410-841-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR191701
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: