Healthcare Provider Details

I. General information

NPI: 1689072001
Provider Name (Legal Business Name): BENJAMIN TIMUNGWA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 HARRY S TRUMAN DR N
LARGO MD
20774-5477
US

IV. Provider business mailing address

PO BOX 417297
BOSTON MA
02241-7297
US

V. Phone/Fax

Practice location:
  • Phone: 240-677-1000
  • Fax:
Mailing address:
  • Phone: 866-623-3869
  • Fax: 302-733-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number123858
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000194
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR234704
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9333438
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number688397
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number006030
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: