Healthcare Provider Details

I. General information

NPI: 1649098591
Provider Name (Legal Business Name): FAMATTA AJAVON DNP, CRNP, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W EDMONSTON DR STE 404
ROCKVILLE MD
20852-1274
US

IV. Provider business mailing address

50 W EDMONSTON DR STE 404
ROCKVILLE MD
20852-1274
US

V. Phone/Fax

Practice location:
  • Phone: 301-762-7723
  • Fax:
Mailing address:
  • Phone: 301-762-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR217568
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: