Healthcare Provider Details

I. General information

NPI: 1952844706
Provider Name (Legal Business Name): IBUKUN AGBEDE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 GEORGIA AVE STE 224
SILVER SPRING MD
20902-5276
US

IV. Provider business mailing address

6122 LANDOVER RD
CHEVERLY MD
20785-1016
US

V. Phone/Fax

Practice location:
  • Phone: 301-593-9800
  • Fax:
Mailing address:
  • Phone: 301-322-2411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR196142
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: