Healthcare Provider Details

I. General information

NPI: 1336456649
Provider Name (Legal Business Name): GLORIA IJEOMA NWOSU-ADIGWE FNP, RN, O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13005 BRESSLER WAY
UPPER MARLBORO MD
20772-6106
US

IV. Provider business mailing address

2045 GRIST MILL LN
PRINCE FREDERICK MD
20678-3858
US

V. Phone/Fax

Practice location:
  • Phone: 301-574-0020
  • Fax:
Mailing address:
  • Phone: 301-646-1859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR245492
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR245492
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT010000519
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number06046
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: