Provider Demographics
NPI:1508423351
Name:ADEBOWALE, MARY DAYO
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DAYO
Last Name:ADEBOWALE
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 1:14 HOLLY HILL LN
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702-2300
Mailing Address - Country:US
Mailing Address - Phone:619-549-9310
Mailing Address - Fax:
Practice Address - Street 1:24035 THREE NOTCH RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:MD
Practice Address - Zip Code:20636-4871
Practice Address - Country:US
Practice Address - Phone:301-373-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR224585363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily