Healthcare Provider Details

I. General information

NPI: 1669047015
Provider Name (Legal Business Name): NGOZI MARYANN JIDEOFOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 WILLOWWOOD CT
HYATTSVILLE MD
20785-4081
US

IV. Provider business mailing address

1622 WILLOWWOOD CT
HYATTSVILLE MD
20785-4081
US

V. Phone/Fax

Practice location:
  • Phone: 240-467-7730
  • Fax:
Mailing address:
  • Phone: 240-467-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00174114
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: