Provider Demographics
NPI:1326491671
Name:NNEBEDUM, AHAOMA ROSE
Entity Type:Individual
Prefix:
First Name:AHAOMA
Middle Name:ROSE
Last Name:NNEBEDUM
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 1:1904 ROBERT BOWIE DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5667
Mailing Address - Country:US
Mailing Address - Phone:240-467-0628
Mailing Address - Fax:202-291-7018
Practice Address - Street 1:1904 ROBERT BOWIE DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5667
Practice Address - Country:US
Practice Address - Phone:240-467-0628
Practice Address - Fax:202-291-7018
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR208742163WP0809X, 363LP0808X
DCRN1032676163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163W00000XNursing Service ProvidersRegistered Nurse