Provider Demographics
NPI:1003394255
Name:FATUSIN, BOSEDE
Entity Type:Individual
Prefix:
First Name:BOSEDE
Middle Name:
Last Name:FATUSIN
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 1:1799 SEA PINE CIR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-1144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1799 SEA PINE CIR
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-1144
Practice Address - Country:US
Practice Address - Phone:240-565-9374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant