Healthcare Provider Details

I. General information

NPI: 1457099293
Provider Name (Legal Business Name): CITYWORLD FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7603 GEORGIA AVE NW STE 101
WASHINGTON DC
20012-1617
US

IV. Provider business mailing address

7700 OLD BRANCH AVE STE B201
CLINTON MD
20735-1605
US

V. Phone/Fax

Practice location:
  • Phone: 202-658-6844
  • Fax: 202-618-6201
Mailing address:
  • Phone: 202-367-3927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. MIRANDA MBUTAMBE
Title or Position: ADMINISTRATOR
Credential: NP
Phone: 202-367-3927