MEDICARE: ITA MBU UH FRU

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	163W00000X	Registered Nurse	RN500342030	DC

General Provider Information

NPI Number	:	1922668250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ITA MBU UH FRU

Provider Business Mailing Address
First Line	:	13916 CASTLE BLVD APT T2
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20904-4952
Country	:	US
Telephone Number	:	202-386-0561
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 18TH ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20018-2738
Country	:	US
Telephone Number	:	202-529-6510
Fax Number	:	202-529-6570

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

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	06/04/2026

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