Provider Demographics
NPI:1881362515
Name:ONIFADE, OLANREWAJU OLUDOTUN (VA, DC, MD)
Entity type:Individual
Prefix:
First Name:OLANREWAJU
Middle Name:OLUDOTUN
Last Name:ONIFADE
Suffix:
Gender:M
Credentials:VA, DC, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24017 AUDUBON TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-5921
Mailing Address - Country:US
Mailing Address - Phone:571-218-5326
Mailing Address - Fax:
Practice Address - Street 1:75 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6103
Practice Address - Country:US
Practice Address - Phone:617-626-9703
Practice Address - Fax:617-626-9703
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2372522363LP0808X
VA0024182548363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024182548Medicaid