Provider Demographics
NPI:1417174889
Name:KANIMODO, FOLASHADE R (FNP-BC, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:FOLASHADE
Middle Name:R
Last Name:KANIMODO
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 EAST COLD SPRING LANE UNIVERSITY HEALTH CENTER
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21251-4999
Mailing Address - Country:US
Mailing Address - Phone:443-885-3236
Mailing Address - Fax:443-885-8232
Practice Address - Street 1:1700 EAST COLD SPRING LANE UNIVERSITY HEALTH CENTER
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21251-4999
Practice Address - Country:US
Practice Address - Phone:443-885-3236
Practice Address - Fax:443-885-8232
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR104161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty