Healthcare Provider Details

I. General information

NPI: 1548571417
Provider Name (Legal Business Name): NNENE UKOHA GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6521 REDGATE CIR
BALTIMORE MD
21228-1146
US

IV. Provider business mailing address

6521 REDGATE CIR
BALTIMORE MD
21228-1146
US

V. Phone/Fax

Practice location:
  • Phone: 443-804-7141
  • Fax:
Mailing address:
  • Phone: 443-804-7141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR130631
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: