MEDICARE: DR. FOLASHADE R KANIMODO FNP-BC, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R104161	MD

General Provider Information

NPI Number	:	1417174889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FOLASHADE R KANIMODO FNP-BC, PMHNP-BC

Provider Business Mailing Address
First Line	:	1700 EAST COLD SPRING LANE UNIVERSITY HEALTH CENTER
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21251-4999
Country	:	US
Telephone Number	:	443-885-3236
Fax Number	:	443-885-8232

Provider Business Practice Location Address
First Line	:	1700 EAST COLD SPRING LANE UNIVERSITY HEALTH CENTER
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21251-4999
Country	:	US
Telephone Number	:	443-885-3236
Fax Number	:	443-885-8232

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	09/11/2020

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