Provider Demographics
NPI:1023667557
Name:OGUNDANA, OLUSEYI IGE (CRNP)
Entity type:Individual
Prefix:
First Name:OLUSEYI
Middle Name:IGE
Last Name:OGUNDANA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 INGLESIDE AVE STE C1
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1796
Mailing Address - Country:US
Mailing Address - Phone:240-413-5721
Mailing Address - Fax:
Practice Address - Street 1:4615 PARK HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-6331
Practice Address - Country:US
Practice Address - Phone:240-413-5721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-07
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR223394363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4884Medicaid