Provider Demographics
NPI:1518314681
Name:AYANWALE, OLAKUNLE IDRIS
Entity Type:Individual
Prefix:
First Name:OLAKUNLE
Middle Name:IDRIS
Last Name:AYANWALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13020 LAUREL BOWIE RD APT 201
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2131
Mailing Address - Country:US
Mailing Address - Phone:240-486-1560
Mailing Address - Fax:
Practice Address - Street 1:13020 LAUREL BOWIE RD APT 201
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-2131
Practice Address - Country:US
Practice Address - Phone:240-486-1560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1040614163W00000X
MDR220724163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse