Provider Demographics
NPI:1912483264
Name:ADEBUSOYE, IFEANYI HENRIETTA
Entity Type:Individual
Prefix:MRS
First Name:IFEANYI
Middle Name:HENRIETTA
Last Name:ADEBUSOYE
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 1:12915 CENTER PARK WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5245
Mailing Address - Country:US
Mailing Address - Phone:301-633-6686
Mailing Address - Fax:240-892-2537
Practice Address - Street 1:12915 CENTER PARK WAY
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-5245
Practice Address - Country:US
Practice Address - Phone:301-633-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR10892163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD900055100Medicaid