Healthcare Provider Details

I. General information

NPI: 1548924459
Provider Name (Legal Business Name): KOFO ABIRU-ADEBAMBO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 RACE ROAD STE 403
ROSEDALE MD
21237-1483
US

IV. Provider business mailing address

822 GUILFORD AVE UNIT 2010
BALTIMORE MD
21202-3707
US

V. Phone/Fax

Practice location:
  • Phone: 443-868-7101
  • Fax: 443-732-0054
Mailing address:
  • Phone: 408-697-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR182386
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: