Provider Demographics
NPI:1164209573
Name:BAGONZA, DOREEN (RN BSN MPH CMSRN)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:BAGONZA
Suffix:
Gender:F
Credentials:RN BSN MPH CMSRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8108 SANDY SPRING RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3582
Mailing Address - Country:US
Mailing Address - Phone:301-318-9833
Mailing Address - Fax:
Practice Address - Street 1:8108 SANDY SPRING RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3582
Practice Address - Country:US
Practice Address - Phone:301-318-9833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR220972163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty