Provider Demographics
NPI:1649649468
Name:OSIDELE, OLUWAKEMI OLUBUNMI (DNP, FNP-C, CRNP)
Entity type:Individual
Prefix:
First Name:OLUWAKEMI
Middle Name:OLUBUNMI
Last Name:OSIDELE
Suffix:
Gender:F
Credentials:DNP, FNP-C, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HILLCREST DR STE A101
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-6105
Mailing Address - Country:US
Mailing Address - Phone:240-575-9940
Mailing Address - Fax:240-575-9941
Practice Address - Street 1:3 HILLCREST DR STE A101
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-6105
Practice Address - Country:US
Practice Address - Phone:240-575-9940
Practice Address - Fax:240-575-9481
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1020313363L00000X
MDR191391363L00000X, 363LF0000X
VA0024172973363LF0000X
WV109994363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1649649468Medicaid