Provider Demographics
NPI:1952860660
Name:FADOJUTIMI, MODUPE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MODUPE
Middle Name:
Last Name:FADOJUTIMI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-9357
Mailing Address - Country:US
Mailing Address - Phone:301-934-4001
Mailing Address - Fax:
Practice Address - Street 1:1 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-9357
Practice Address - Country:US
Practice Address - Phone:301-934-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194540363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care