Basic Information
| Provider Information | |||||||||
| NPI: | 1063858173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OJENIYI | ||||||||
| FirstName: | TRACY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 851 TRAFALGAR CT STE 200E | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076670444 | ||||||||
| FaxNumber: | 4076674338 | ||||||||
| Practice Location | |||||||||
| Address1: | 11890 HEALING WAY | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209047917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406374000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2013 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN1007894 | DC | N | Nursing Service Providers | Registered Nurse | 367500000X | R184724 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | MD | MEDICAID |