Healthcare Provider Details

I. General information

NPI: 1417603200
Provider Name (Legal Business Name): SERENA LUIGIA GONZAGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 OLD GEORGETOWN RD
BETHESDA MD
20814-1422
US

IV. Provider business mailing address

758 SILVER SPRING AVE
SILVER SPRING MD
20910-4661
US

V. Phone/Fax

Practice location:
  • Phone: 301-896-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR237090
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: