Provider Demographics
NPI:1336590694
Name:ADESANYA, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:ADESANYA
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 1:9001 CONTEE RD
Mailing Address - Street 2:APT B
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2139
Mailing Address - Country:US
Mailing Address - Phone:240-334-8717
Mailing Address - Fax:
Practice Address - Street 1:9001 CONTEE RD
Practice Address - Street 2:APT B
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-2139
Practice Address - Country:US
Practice Address - Phone:240-334-8717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12215374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide