Healthcare Provider Details

I. General information

NPI: 1972292159
Provider Name (Legal Business Name): COMFORT B OGUNLOWO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 OLD COURT RD
RANDALLSTOWN MD
21133-5104
US

IV. Provider business mailing address

9535 WESLAND CIR
RANDALLSTOWN MD
21133-2040
US

V. Phone/Fax

Practice location:
  • Phone: 443-985-1614
  • Fax:
Mailing address:
  • Phone: 443-985-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR208424
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: