Provider Demographics
NPI:1609549732
Name:AGBOOLA, ABIMBOLA A
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:A
Last Name:AGBOOLA
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 1:2007 MARYLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3121
Mailing Address - Country:US
Mailing Address - Phone:240-581-0359
Mailing Address - Fax:
Practice Address - Street 1:2007 MARYLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-3121
Practice Address - Country:US
Practice Address - Phone:240-581-0359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA00195459Medicaid