Provider Demographics
NPI:1518458363
Name:SOFOLUWE, OLUSEYI ADEBOLA (CRNP)
Entity type:Individual
Prefix:
First Name:OLUSEYI
Middle Name:ADEBOLA
Last Name:SOFOLUWE
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 CARROLL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6311
Mailing Address - Country:US
Mailing Address - Phone:301-891-2500
Mailing Address - Fax:
Practice Address - Street 1:7610 CARROLL AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6311
Practice Address - Country:US
Practice Address - Phone:301-891-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-27
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1011899363L00000X
MDR177845363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner