Provider Demographics
NPI:1356017198
Name:OMOBO, OLUWATOBI (NP)
Entity Type:Individual
Prefix:
First Name:OLUWATOBI
Middle Name:
Last Name:OMOBO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9831 GREENBELT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-6224
Mailing Address - Country:US
Mailing Address - Phone:301-792-0855
Mailing Address - Fax:
Practice Address - Street 1:9831 GREENBELT RD STE 103
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6224
Practice Address - Country:US
Practice Address - Phone:301-792-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR228974363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health