Provider Demographics
NPI:1497398713
Name:AMOSU, OLUTAYO SHADE
Entity Type:Individual
Prefix:
First Name:OLUTAYO
Middle Name:SHADE
Last Name:AMOSU
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 1:16229 PRESIDIO WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1913
Mailing Address - Country:US
Mailing Address - Phone:301-256-4400
Mailing Address - Fax:
Practice Address - Street 1:16229 PRESIDIO WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1913
Practice Address - Country:US
Practice Address - Phone:301-256-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide