Provider Demographics
NPI:1225477987
Name:AGBOOLA, OLUBISOLA MARYAM
Entity Type:Individual
Prefix:
First Name:OLUBISOLA
Middle Name:MARYAM
Last Name:AGBOOLA
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 1:5457 MADISON WAY
Mailing Address - Street 2:#6
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1053
Mailing Address - Country:US
Mailing Address - Phone:240-547-8117
Mailing Address - Fax:
Practice Address - Street 1:6531 LANDOVER RD
Practice Address - Street 2:#103
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1431
Practice Address - Country:US
Practice Address - Phone:244-054-7811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide