Healthcare Provider Details

I. General information

NPI: 1245590983
Provider Name (Legal Business Name): LYDIA NDI EJACHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 PISCATAWAY RD STE 410
CLINTON MD
20735-2555
US

IV. Provider business mailing address

780 FAIRVIEW AVE 302
TAKOMA PARK MD
20912-5978
US

V. Phone/Fax

Practice location:
  • Phone: 240-688-5033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR229134
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: