Healthcare Provider Details

I. General information

NPI: 1679174700
Provider Name (Legal Business Name): NKEMDILIM OKONKWO PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13922 BALTIMORE AVE
LAUREL MD
20707-5009
US

IV. Provider business mailing address

7716 CLOISTER PL
GREENBELT MD
20770-3029
US

V. Phone/Fax

Practice location:
  • Phone: 301-483-3333
  • Fax:
Mailing address:
  • Phone: 301-648-9593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR240590
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: