Healthcare Provider Details

I. General information

NPI: 1952928905
Provider Name (Legal Business Name): MARIYAM IBIRONKE POPOOLA DNP, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 HOSPITAL DR
CHEVERLY MD
20785-1189
US

IV. Provider business mailing address

3001 HOSPITAL DR
CHEVERLY MD
20785-1189
US

V. Phone/Fax

Practice location:
  • Phone: 301-618-6100
  • Fax:
Mailing address:
  • Phone: 301-618-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR199351
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: