Healthcare Provider Details

I. General information

NPI: 1821639634
Provider Name (Legal Business Name): BEATRICE MOUGA KOUEMOU CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 PARK AVE STE 200
BALTIMORE MD
21201-5634
US

IV. Provider business mailing address

1040 PARK AVE STE 200
BALTIMORE MD
21201-5634
US

V. Phone/Fax

Practice location:
  • Phone: 667-400-0223
  • Fax: 443-738-0301
Mailing address:
  • Phone: 667-400-0223
  • Fax: 443-738-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF346954-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR210351
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: