Healthcare Provider Details

I. General information

NPI: 1841749330
Provider Name (Legal Business Name): IDARA IBOK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12073 TECH RD STE B
SILVER SPRING MD
20904-7874
US

IV. Provider business mailing address

1500 FOREST GLEN RD
SILVER SPRING MD
20910-1460
US

V. Phone/Fax

Practice location:
  • Phone: 301-593-1315
  • Fax:
Mailing address:
  • Phone: 301-754-7991
  • Fax: 301-754-7990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR171690
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR171690
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: