Healthcare Provider Details

I. General information

NPI: 1952886137
Provider Name (Legal Business Name): EDITH N EMELOGU CRNP-FAMILY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N. PACA STREET FIRST FLOOR
BALTIMORE MD
21201
US

IV. Provider business mailing address

1714 EUTAW PLACE STE 2A
BALTIMORE MD
21217
US

V. Phone/Fax

Practice location:
  • Phone: 410-779-9609
  • Fax: 773-552-4758
Mailing address:
  • Phone: 410-779-9609
  • Fax: 443-552-4758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR192245
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: