Healthcare Provider Details

I. General information

NPI: 1356609754
Provider Name (Legal Business Name): CONSTANCE N GAWUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 07/01/2024
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HEARTLAND CT
UPPER MARLBORO MD
20774-6098
US

IV. Provider business mailing address

1200 HEARTLAND CT
UPPER MARLBORO MD
20774-6098
US

V. Phone/Fax

Practice location:
  • Phone: 301-978-6383
  • Fax:
Mailing address:
  • Phone: 301-978-6383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP1054202
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1054202
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: