Healthcare Provider Details

I. General information

NPI: 1548140080
Provider Name (Legal Business Name): GRACE UKOMADU
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9138 LENNINGS LN
BALTIMORE MD
21237-4307
US

IV. Provider business mailing address

9138 LENNINGS LN
BALTIMORE MD
21237-4307
US

V. Phone/Fax

Practice location:
  • Phone: 667-228-8003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR251328
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: