Healthcare Provider Details

I. General information

NPI: 1316303563
Provider Name (Legal Business Name): MINNIE NDEM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MARKS MANOR CT
RANDALLSTOWN MD
21133-1304
US

IV. Provider business mailing address

6 MARKS MANOR CT
RANDALLSTOWN MD
21133-1304
US

V. Phone/Fax

Practice location:
  • Phone: 443-922-8963
  • Fax: 443-272-6425
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF1215414
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number132005
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: