Provider Demographics
NPI:1871088187
Name:ADEBANWO, ABIDEMI Y
Entity type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:Y
Last Name:ADEBANWO
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 1:9203 WELLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2720
Mailing Address - Country:US
Mailing Address - Phone:301-272-5520
Mailing Address - Fax:
Practice Address - Street 1:9203 WELLINGTON CT
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2720
Practice Address - Country:US
Practice Address - Phone:301-272-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR210964363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty