Provider Demographics
NPI:1548924459
Name:ABIRU-ADEBAMBO, KOFO
Entity type:Individual
Prefix:
First Name:KOFO
Middle Name:
Last Name:ABIRU-ADEBAMBO
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 1:822 GUILFORD AVE UNIT 2010
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-3707
Mailing Address - Country:US
Mailing Address - Phone:408-697-9392
Mailing Address - Fax:
Practice Address - Street 1:1232 RACE ROAD
Practice Address - Street 2:STE 403
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-1483
Practice Address - Country:US
Practice Address - Phone:443-868-7101
Practice Address - Fax:443-732-0054
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR182386363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health