Healthcare Provider Details

I. General information

NPI: 1154816627
Provider Name (Legal Business Name): IMUETINYAN CONSTANCE OGBNORO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4273 58TH AVE APT 3
BLADENSBURG MD
20710-1919
US

IV. Provider business mailing address

4273 58TH AVE APT 3
BLADENSBURG MD
20710-1919
US

V. Phone/Fax

Practice location:
  • Phone: 240-764-9153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA13748
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: