Provider Demographics
NPI:1346892031
Name:BOSUN-OGUNDARE, IBIYEMI
Entity Type:Individual
Prefix:
First Name:IBIYEMI
Middle Name:
Last Name:BOSUN-OGUNDARE
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 1:8899 FLOWERSTOCK ROW APT 204
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3094
Mailing Address - Country:US
Mailing Address - Phone:240-772-8085
Mailing Address - Fax:
Practice Address - Street 1:2512 24TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2126
Practice Address - Country:US
Practice Address - Phone:202-832-8340
Practice Address - Fax:202-838-8341
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14352374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide