Healthcare Provider Details

I. General information

NPI: 1922759570
Provider Name (Legal Business Name): MARCIA ANGELLA BURRELL-ODEYEMI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10539 SUGARBERRY ST
WALDORF MD
20603-5715
US

IV. Provider business mailing address

10539 SUGARBERRY ST
WALDORF MD
20603-5715
US

V. Phone/Fax

Practice location:
  • Phone: 301-412-5838
  • Fax:
Mailing address:
  • Phone: 301-412-5838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR149910
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR149910
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: