MEDICARE: ETHELAURA CARE CLINICS LLC

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

General Provider Information

NPI Number	:	1770470254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHELAURA CARE CLINICS LLC

Provider Business Mailing Address
First Line	:	12530 FAIRWOOD PKWY STE 102-307
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-6356
Country	:	US
Telephone Number	:	301-728-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	12530 FAIRWOOD PKWY STE 102-307
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20720-6356
Country	:	US
Telephone Number	:	301-728-7200
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ERONMWON YVONNE OKONJO
Credential	:
Telephone Number	:	301-728-7200

Provider Enumeration Date	:	06/18/2025
Last Update Date	:	09/01/2025

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