Provider Demographics
NPI:1457943201
Name:LAWAL, BOSE KEMI
Entity Type:Individual
Prefix:
First Name:BOSE
Middle Name:KEMI
Last Name:LAWAL
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 1:12716 WEDGEDALE CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6413
Mailing Address - Country:US
Mailing Address - Phone:240-614-3991
Mailing Address - Fax:
Practice Address - Street 1:5513 ILLINOIS AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-2937
Practice Address - Country:US
Practice Address - Phone:202-882-9310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00127752374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide