Provider Demographics
NPI:1073873576
Name:MOSOKE, HENRIETTA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:
Last Name:MOSOKE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:HENRIETTA
Other - Middle Name:
Other - Last Name:EKUKOLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HHA
Mailing Address - Street 1:1800 N CHARLES ST STE 804
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5987
Mailing Address - Country:US
Mailing Address - Phone:240-898-1810
Mailing Address - Fax:240-493-8657
Practice Address - Street 1:415 PRAIRIE CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5786
Practice Address - Country:US
Practice Address - Phone:301-281-1907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCR1038649363LP0808X
374U00000X
MDR217639363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1073873576Medicaid