Provider Demographics
NPI:1508324971
Name:OGUNLOWO-OMOBHUDE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:OGUNLOWO-OMOBHUDE
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 1:4505 BLACKBIRDS FOLLY LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-5803
Mailing Address - Country:US
Mailing Address - Phone:240-602-7035
Mailing Address - Fax:
Practice Address - Street 1:420 CRAIN HWY S
Practice Address - Street 2:STE 3
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3657
Practice Address - Country:US
Practice Address - Phone:240-602-7035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1508324971363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty