Provider Demographics
NPI:1477811800
Name:OGBU, CALISTA (DNP)
Entity Type:Individual
Prefix:
First Name:CALISTA
Middle Name:
Last Name:OGBU
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 SAINT BARNABAS RD
Mailing Address - Street 2:STE G
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-1842
Mailing Address - Country:US
Mailing Address - Phone:240-200-6838
Mailing Address - Fax:800-853-3149
Practice Address - Street 1:4302 SAINT BARNABAS RD STE G
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-1842
Practice Address - Country:US
Practice Address - Phone:240-200-6838
Practice Address - Fax:800-853-3149
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR207370363LF0000X, 363LP0808X
DCRN1031030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC083767643Medicaid
MDPENDINGMedicaid