Healthcare Provider Details

I. General information

NPI: 1619812427
Provider Name (Legal Business Name): OLUWAKEMISOLA ABIODUN KOKU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 PEBBLE BEACH CT
WALDORF MD
20602-4110
US

IV. Provider business mailing address

4665 PEBBLE BEACH CT
WALDORF MD
20602-4110
US

V. Phone/Fax

Practice location:
  • Phone: 737-268-9101
  • Fax:
Mailing address:
  • Phone: 737-268-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP034976
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: