Healthcare Provider Details

I. General information

NPI: 1073273736
Provider Name (Legal Business Name): ELIZABETH ANYA IWEALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 WIPKEY CT
BOWIE MD
20720-3268
US

IV. Provider business mailing address

9101 WIPKEY CT
BOWIE MD
20720-3268
US

V. Phone/Fax

Practice location:
  • Phone: 240-491-2838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR130009
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: