=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811183973
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH GBEMISOLA ADEDEJI CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 02/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12817 FOX FERN LN
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20871-4040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-755-1056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1119 EAST-WEST HWY, SILVER SPRING, MD 20910
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20910-1206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-207-6878
-----------------------------------------------------
Fax | 888-511-3073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R202235
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------