=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073491106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMOLOLA OLUWASEUN OGUNGBILE CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2025
-----------------------------------------------------
Last Update Date | 08/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8015 APPLE VALLEY DR
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21122-4174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-841-9998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7736 ROTHERHAM DR
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21076-1460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-841-9998
-----------------------------------------------------
Fax | 410-841-9998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | R191701
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------