Provider Demographics
NPI:1285932038
Name:ADEBOGUN, BOLADALE ADEBIMPE
Entity type:Individual
Prefix:
First Name:BOLADALE
Middle Name:ADEBIMPE
Last Name:ADEBOGUN
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 1:62 RIDGELAWN RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3647
Mailing Address - Country:US
Mailing Address - Phone:443-762-7949
Mailing Address - Fax:
Practice Address - Street 1:62 RIDGELAWN RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3647
Practice Address - Country:US
Practice Address - Phone:443-762-7949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101104163W00000X, 164W00000X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No374U00000XNursing Service Related ProvidersHome Health Aide