Healthcare Provider Details

I. General information

NPI: 1568827855
Provider Name (Legal Business Name): MARITA ATEHAKOH FORMIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARITA ATEHAKOH FORMIN NP

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7375 EXECUTIVE PL
LANHAM MD
20706-2278
US

IV. Provider business mailing address

7375 EXECUTIVE PL STE 200
LANHAM MD
20706-6234
US

V. Phone/Fax

Practice location:
  • Phone: 202-940-2022
  • Fax:
Mailing address:
  • Phone: 202-940-2022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR249853
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: