Healthcare Provider Details

I. General information

NPI: 1801626437
Provider Name (Legal Business Name): BERTHE I TCHAYA NOUBOSSIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8210 CASTANEA LN
DERWOOD MD
20855-2581
US

IV. Provider business mailing address

3522 LADOVA WAY
SPRINGDALE MD
20774
US

V. Phone/Fax

Practice location:
  • Phone: 301-549-0335
  • Fax:
Mailing address:
  • Phone: 240-383-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR215535
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR215535
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1037458
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: