Healthcare Provider Details

I. General information

NPI: 1710742044
Provider Name (Legal Business Name): CHINONYEREM OLUMBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 ANNAPOLIS RD
LANHAM MD
20706-2060
US

IV. Provider business mailing address

12108 ROCKLEDGE DR
BOWIE MD
20715-3233
US

V. Phone/Fax

Practice location:
  • Phone: 301-850-1148
  • Fax:
Mailing address:
  • Phone: 443-839-8661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: