Provider Demographics
NPI:1558829481
Name:ETTEYIT, MOTUNRAYO TUNTUN (CRNP)
Entity Type:Individual
Prefix:MS
First Name:MOTUNRAYO
Middle Name:TUNTUN
Last Name:ETTEYIT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MOTUNRAYO
Other - Middle Name:TUNTUN
Other - Last Name:OGUNFIDITIMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:1665 WOODBROOKE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-546-6650
Practice Address - Fax:410-546-2656
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR211533363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid