MEDICARE: EZINNA ULOMA MBALEWE RN

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	171M00000X	Case Manager/Care Coordinator	R139466	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1730666546	OTHER		NATIONAL PROVIDER ID

General Provider Information

NPI Number	:	1629555354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EZINNA ULOMA MBALEWE RN

Provider Business Mailing Address
First Line	:	3140 BEETHOVEN WAY
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20904-6860
Country	:	US
Telephone Number	:	301-661-8365
Fax Number	:

Provider Business Practice Location Address
First Line	:	14725 GOOD HOPE RD
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20905-6020
Country	:	US
Telephone Number	:	240-970-5310
Fax Number	:

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

Provider Enumeration Date	:	07/25/2018
Last Update Date	:	07/25/2018

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