Provider Demographics
NPI:1902201395
Name:ADEMOYE, MUKAILA ADISA
Entity Type:Individual
Prefix:
First Name:MUKAILA
Middle Name:ADISA
Last Name:ADEMOYE
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 1:3807 64TH AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1838
Mailing Address - Country:US
Mailing Address - Phone:202-763-2898
Mailing Address - Fax:
Practice Address - Street 1:3807 64TH AVE APT 202
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20784-1838
Practice Address - Country:US
Practice Address - Phone:202-763-2898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA10515374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide