Healthcare Provider Details

I. General information

NPI: 1255970380
Provider Name (Legal Business Name): JULIENNE EBONGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10313 GEORGIA AVE STE 307
SILVER SPRING MD
20902-5006
US

IV. Provider business mailing address

2 UNIVERSITY PLZ STE 204
HACKENSACK NJ
07601-6211
US

V. Phone/Fax

Practice location:
  • Phone: 301-754-2222
  • Fax:
Mailing address:
  • Phone: 551-295-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR205045
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: