Provider Demographics
NPI:1417703117
Name:OLUSOGA, CLEMENTINA (NP)
Entity type:Individual
Prefix:
First Name:CLEMENTINA
Middle Name:
Last Name:OLUSOGA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 RIDGEBROOK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9477
Mailing Address - Country:US
Mailing Address - Phone:301-377-8431
Mailing Address - Fax:
Practice Address - Street 1:909 RIDGEBROOK RD STE 300
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:MD
Practice Address - Zip Code:21152-9477
Practice Address - Country:US
Practice Address - Phone:301-377-8431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD987724651363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner