Provider Demographics
NPI:1245715861
Name:OLUSEGUN, ABIMBOLA
Entity type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:
Last Name:OLUSEGUN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 LADOVA WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2594
Mailing Address - Country:US
Mailing Address - Phone:240-645-5710
Mailing Address - Fax:
Practice Address - Street 1:7600 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1616
Practice Address - Country:US
Practice Address - Phone:202-723-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN500020492164W00000X
DCHHA14016374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide