Provider Demographics
NPI:1851855902
Name:BALOGUN, MARIAM ADETOLA
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:ADETOLA
Last Name:BALOGUN
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 1:4265 58TH AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-1922
Mailing Address - Country:US
Mailing Address - Phone:347-972-8408
Mailing Address - Fax:
Practice Address - Street 1:4265 58TH AVE APT 7
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-1922
Practice Address - Country:US
Practice Address - Phone:347-972-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14195374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide