Healthcare Provider Details

I. General information

NPI: 1366887663
Provider Name (Legal Business Name): MARYROSE IFEOMA CHUKWUNAEMELI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7411 RIGGS RD STE 428
HYATTSVILLE MD
20783-4246
US

IV. Provider business mailing address

9804 DOLBY AVE
GLENN DALE MD
20769-9233
US

V. Phone/Fax

Practice location:
  • Phone: 301-408-0350
  • Fax: 855-850-9065
Mailing address:
  • Phone: 667-303-6165
  • Fax: 667-303-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0004973
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: