Provider Demographics
NPI:1952844706
Name:AGBEDE, IBUKUN (CRNP)
Entity Type:Individual
Prefix:
First Name:IBUKUN
Middle Name:
Last Name:AGBEDE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6122 LANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1016
Mailing Address - Country:US
Mailing Address - Phone:301-322-2411
Mailing Address - Fax:
Practice Address - Street 1:9801 GEORGIA AVE STE 224
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5276
Practice Address - Country:US
Practice Address - Phone:301-593-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR196142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily