Provider Demographics
NPI:1427651561
Name:OSUNKIYESI, BOLA D
Entity type:Individual
Prefix:
First Name:BOLA
Middle Name:D
Last Name:OSUNKIYESI
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 1:6239 SETON HILLS LN
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6098
Mailing Address - Country:US
Mailing Address - Phone:443-469-9528
Mailing Address - Fax:
Practice Address - Street 1:6239 SETON HILLS LN
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-6098
Practice Address - Country:US
Practice Address - Phone:443-469-9528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR190321363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health