Provider Demographics
NPI:1164193462
Name:OMOIJUANFO, OBEHI
Entity Type:Individual
Prefix:
First Name:OBEHI
Middle Name:
Last Name:OMOIJUANFO
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 1:14905 DOVEHEART LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3084
Mailing Address - Country:US
Mailing Address - Phone:240-520-3197
Mailing Address - Fax:
Practice Address - Street 1:14905 DOVEHEART LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-3084
Practice Address - Country:US
Practice Address - Phone:240-520-3197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202569363LP0808X
261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health