Healthcare Provider Details

I. General information

NPI: 1811573843
Provider Name (Legal Business Name): IJEOMA G AHAGHOTU FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2021
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 NORTHVIEW DR STE 38
BOWIE MD
20716-2600
US

IV. Provider business mailing address

4305 NORTHVIEW DR STE 38
BOWIE MD
20716-2600
US

V. Phone/Fax

Practice location:
  • Phone: 301-235-9999
  • Fax: 301-235-9950
Mailing address:
  • Phone: 301-235-9999
  • Fax: 301-235-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR192482
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1020859
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: