Provider Demographics
NPI:1336796465
Name:ADENUGA, OMOBOLANLE M (CRNP-F)
Entity Type:Individual
Prefix:
First Name:OMOBOLANLE
Middle Name:M
Last Name:ADENUGA
Suffix:
Gender:F
Credentials:CRNP-F
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 ELLICOTT MILLS DR STE B2
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4549
Mailing Address - Country:US
Mailing Address - Phone:443-272-5506
Mailing Address - Fax:
Practice Address - Street 1:11636 PORT ROYAL AVE
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-5193
Practice Address - Country:US
Practice Address - Phone:240-755-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR214177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner