Provider Demographics
NPI:1194396366
Name:FATOMILUYI, CHRISTIANAH OMOLOLA
Entity Type:Individual
Prefix:
First Name:CHRISTIANAH
Middle Name:OMOLOLA
Last Name:FATOMILUYI
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 1:2206 BRIGHTSEAT RD APT 102
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3508
Mailing Address - Country:US
Mailing Address - Phone:240-495-9283
Mailing Address - Fax:
Practice Address - Street 1:2206 BRIGHTSEAT RD APT 102
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-3508
Practice Address - Country:US
Practice Address - Phone:240-495-9283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCNA0000807207376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide