Healthcare Provider Details

I. General information

NPI: 1124539861
Provider Name (Legal Business Name): CYNTHIA N OKONKWO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2017
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 CENTENNIAL LN
ELLICOTT CITY MD
21042
US

IV. Provider business mailing address

3300 CENTENNIAL LN
ELLICOTT CITY MD
21042-3600
US

V. Phone/Fax

Practice location:
  • Phone: 410-750-9439
  • Fax:
Mailing address:
  • Phone: 410-750-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP134577
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR205350
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: