Healthcare Provider Details

I. General information

NPI: 1417576463
Provider Name (Legal Business Name): ANNIE E TABI PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNIE E OGUNSON PMHNP-BC

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 MOUNTAIN RD
PASADENA MD
21122-7203
US

IV. Provider business mailing address

292 SAINT MICHAELS CIR
ODENTON MD
21113-1086
US

V. Phone/Fax

Practice location:
  • Phone: 443-548-3733
  • Fax: 410-360-1675
Mailing address:
  • Phone: 240-413-8399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR191166
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number20221161319
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: