Provider Demographics
NPI:1982188231
Name:IBIJEMILUSI, CAROLINE
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:IBIJEMILUSI
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 1:9470 ANNAPOLIS RD STE 402
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3059
Mailing Address - Country:US
Mailing Address - Phone:240-770-6689
Mailing Address - Fax:240-667-2190
Practice Address - Street 1:9470 ANNAPOLIS RD STE 402
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3059
Practice Address - Country:US
Practice Address - Phone:240-770-6689
Practice Address - Fax:240-667-2190
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-22
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR160656363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care