MEDICARE: CHIDI ROOVELT NWACHUKWU CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R191711	MD
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	R191711	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R191711	OTHER	MD	CRNP #

General Provider Information

NPI Number	:	1578031977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHIDI ROOVELT NWACHUKWU CRNP

Provider Business Mailing Address
First Line	:	10700 TARA CT
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20774-2124
Country	:	US
Telephone Number	:	301-806-7473
Fax Number	:

Provider Business Practice Location Address
First Line	:	7375 EXECUTIVE PL
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-2278
Country	:	US
Telephone Number	:	301-806-7473
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2018
Last Update Date	:	07/13/2023

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