Healthcare Provider Details

I. General information

NPI: 1497385538
Provider Name (Legal Business Name): IFEYINWA MADUKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 ANNAPOLIS RD STE 2
GLENN DALE MD
20769-9179
US

IV. Provider business mailing address

12100 ANNAPOLIS RD UNIT 2
GLENN DALE MD
20769-9179
US

V. Phone/Fax

Practice location:
  • Phone: 301-383-0142
  • Fax: 443-274-4791
Mailing address:
  • Phone:
  • Fax: 443-274-4791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR178338
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: