=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245719202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILOMENA ONWUEGBULE CRNP FAMILY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2018
-----------------------------------------------------
Last Update Date | 08/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13992 BALTIMORE AVE STE 200
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20707-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-264-6704
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7947 MONROVIA DR
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21076-1098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-903-9948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R129518
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------