Healthcare Provider Details

I. General information

NPI: 1851089726
Provider Name (Legal Business Name): IRENE MOSONGO MUTECK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 E NORTH AVE
BALTIMORE MD
21213-1408
US

IV. Provider business mailing address

5700 BELRIDGE RD
UPPER MARLBORO MD
20772-3621
US

V. Phone/Fax

Practice location:
  • Phone: 443-452-3692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR217674
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR217674
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: