Provider Demographics
NPI:1346624939
Name:FAGBENRO, LATEEFAT OMOLARA
Entity Type:Individual
Prefix:MISS
First Name:LATEEFAT
Middle Name:OMOLARA
Last Name:FAGBENRO
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 1:3318 DODGE PARK RD APT 101
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2114
Mailing Address - Country:US
Mailing Address - Phone:240-413-1823
Mailing Address - Fax:
Practice Address - Street 1:3318 DODGE PARK RD APT 101
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-2114
Practice Address - Country:US
Practice Address - Phone:240-413-1823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDNA00809491390200000X
DCHHA11333374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program