Provider Demographics
NPI:1508559675
Name:SHADARE, ABIMBOLA
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:SHADARE
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 1:4312 ARABELLA CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-9343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4312 ARABELLA CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-9343
Practice Address - Country:US
Practice Address - Phone:240-593-2260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1042439163WP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health