Provider Demographics
NPI:1477181857
Name:OMOJOLA, IWALOLA STELLA
Entity Type:Individual
Prefix:MISS
First Name:IWALOLA
Middle Name:STELLA
Last Name:OMOJOLA
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 1:111 BUTTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3873
Mailing Address - Country:US
Mailing Address - Phone:443-898-2343
Mailing Address - Fax:
Practice Address - Street 1:111 BUTTONWOOD CT
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-3873
Practice Address - Country:US
Practice Address - Phone:443-898-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203351363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health