=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588113351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GANIYAT ADEYEMO CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2016
-----------------------------------------------------
Last Update Date | 07/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7801 STANLEY LN
-----------------------------------------------------
City | SEVERN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21144-1572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-381-1604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 RIDGELY AVE STE 231
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-1092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-381-1604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R197794
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R197794
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------