Provider Demographics
NPI:1548720071
Name:ADEWUNMI, KIKELOMO
Entity type:Individual
Prefix:
First Name:KIKELOMO
Middle Name:
Last Name:ADEWUNMI
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 1:3240 BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1228
Mailing Address - Country:US
Mailing Address - Phone:410-878-0655
Mailing Address - Fax:
Practice Address - Street 1:3240 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1228
Practice Address - Country:US
Practice Address - Phone:410-878-0655
Practice Address - Fax:410-878-0614
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR207261363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health