Provider Demographics
NPI:1346830940
Name:OLUSANYA, MOSUN
Entity Type:Individual
Prefix:
First Name:MOSUN
Middle Name:
Last Name:OLUSANYA
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 1:7918 JONES BRANCH DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3319
Mailing Address - Country:US
Mailing Address - Phone:703-946-1664
Mailing Address - Fax:
Practice Address - Street 1:7918 JONES BRANCH DR STE 400
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3319
Practice Address - Country:US
Practice Address - Phone:703-946-1664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-212487251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAHCO-212487OtherHOME CARE ORGANIZATION