Provider Demographics
NPI:1538724604
Name:FANIMO, OLUWATOSIN A
Entity type:Individual
Prefix:
First Name:OLUWATOSIN
Middle Name:A
Last Name:FANIMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12910 N POINT LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2356
Mailing Address - Country:US
Mailing Address - Phone:202-246-3013
Mailing Address - Fax:
Practice Address - Street 1:2000 W BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-1558
Practice Address - Country:US
Practice Address - Phone:202-246-3013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-04
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR183671363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health