=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972230639
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRACTISTAT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2022
-----------------------------------------------------
Last Update Date | 08/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5457 TWIN KNOLLS RD STE 300
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-3296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-461-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5457 TWIN KNOLLS RD STE 300
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-3296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-461-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MUNIRATU FABODE
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 240-461-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------