Provider Demographics
NPI:1184311953
Name:AJAYI, OMODELE MODUPE (NP)
Entity type:Individual
Prefix:MRS
First Name:OMODELE
Middle Name:MODUPE
Last Name:AJAYI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 GLEN ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3373
Mailing Address - Country:US
Mailing Address - Phone:443-356-7128
Mailing Address - Fax:
Practice Address - Street 1:8160 GLEN ARBOR DR
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-3373
Practice Address - Country:US
Practice Address - Phone:443-356-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR193595363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health