Provider Demographics
NPI:1184221236
Name:IROBEREACHI, EZINWANNE JUDITH
Entity Type:Individual
Prefix:
First Name:EZINWANNE
Middle Name:JUDITH
Last Name:IROBEREACHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15802 PACIFIC CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1632
Mailing Address - Country:US
Mailing Address - Phone:301-377-9313
Mailing Address - Fax:
Practice Address - Street 1:2203 PHILADELPHIA RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-1109
Practice Address - Country:US
Practice Address - Phone:410-612-0275
Practice Address - Fax:410-612-0287
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR182841363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health