Provider Demographics
NPI:1285126912
Name:UNEGBU, TITILAYO ADENIKE
Entity type:Individual
Prefix:
First Name:TITILAYO
Middle Name:ADENIKE
Last Name:UNEGBU
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 1:13106 CONTEE MANOR RD
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3299
Mailing Address - Country:US
Mailing Address - Phone:410-440-8763
Mailing Address - Fax:
Practice Address - Street 1:2021 CROSS CHURCH WAY
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-2398
Practice Address - Country:US
Practice Address - Phone:410-440-8763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMDR117409163W00000X
MD2022091446363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU-521-793-031-832OtherDRIVER'S LICENSE