Healthcare Provider Details

I. General information

NPI: 1962714204
Provider Name (Legal Business Name): KETTY M NGONA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7310 RITCHIE HWY STE 612
GLEN BURNIE MD
21061-3291
US

IV. Provider business mailing address

7735 HOLLINS CHAPEL CT
GLEN BURNIE MD
21060-8396
US

V. Phone/Fax

Practice location:
  • Phone: 443-491-7854
  • Fax: 443-288-4808
Mailing address:
  • Phone: 443-491-7854
  • Fax: 443-288-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR170567
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR170567
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: