Provider Demographics
NPI:1972900769
Name:OMOYENI, OLURANTI A (ACNP,CRNP)
Entity Type:Individual
Prefix:
First Name:OLURANTI
Middle Name:A
Last Name:OMOYENI
Suffix:
Gender:F
Credentials:ACNP,CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 SMITH AVE
Mailing Address - Street 2:SUITE, 210
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3652
Mailing Address - Country:US
Mailing Address - Phone:410-735-6665
Mailing Address - Fax:410-735-6670
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:ALPHA COMMONS BUILDING, ST 105
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0477
Practice Address - Fax:410-550-0732
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR182449363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care