Healthcare Provider Details

I. General information

NPI: 1568308328
Provider Name (Legal Business Name): ETIETOP UBAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 OLD BRANCH AVE
CLINTON MD
20735-1608
US

IV. Provider business mailing address

7801 OLD BRANCH AVE STE 405
CLINTON MD
20735-1644
US

V. Phone/Fax

Practice location:
  • Phone: 240-559-7353
  • Fax:
Mailing address:
  • Phone: 240-559-7353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR263408
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: