Healthcare Provider Details

I. General information

NPI: 1457947590
Provider Name (Legal Business Name): NNENNA JOYCE EYIBA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15027 PINE TOP LN
BURTONSVILLE MD
20866-1318
US

IV. Provider business mailing address

15027 PINE TOP LN
BURTONSVILLE MD
20866-1318
US

V. Phone/Fax

Practice location:
  • Phone: 240-486-4918
  • Fax:
Mailing address:
  • Phone: 240-486-4918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number0001282133
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: