Healthcare Provider Details

I. General information

NPI: 1336704584
Provider Name (Legal Business Name): LABAKE G OGUNNUPE CRNP-PMH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 RIVERSIDE DR STE A
SALISBURY MD
21801-5369
US

IV. Provider business mailing address

547 RIVERSIDE DR STE A
SALISBURY MD
21801-5369
US

V. Phone/Fax

Practice location:
  • Phone: 443-355-7517
  • Fax: 443-733-6050
Mailing address:
  • Phone: 202-276-9353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR162454
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: