Provider Demographics
NPI:1679014641
Name:FAMODU, FOLASHADE
Entity Type:Individual
Prefix:
First Name:FOLASHADE
Middle Name:
Last Name:FAMODU
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 1:33 CHESTNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-1515
Mailing Address - Country:US
Mailing Address - Phone:443-803-6458
Mailing Address - Fax:
Practice Address - Street 1:33 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-1515
Practice Address - Country:US
Practice Address - Phone:443-803-6458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR175637363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health