Healthcare Provider Details

I. General information

NPI: 1801604913
Provider Name (Legal Business Name): MARY TOKUNBO FAGBOHUN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 OLD POTOMAC CHURCH RD
STAFFORD VA
22554-7380
US

IV. Provider business mailing address

2433 SAN MARCO LN
EDMOND OK
73034-2354
US

V. Phone/Fax

Practice location:
  • Phone: 510-585-6551
  • Fax:
Mailing address:
  • Phone: 510-585-6551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0087816
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: