Provider Demographics
NPI:1376801118
Name:MBUTAMBE, MIRANDA BESSEM (CRNP PMHNP DNP)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:BESSEM
Last Name:MBUTAMBE
Suffix:
Gender:F
Credentials:CRNP PMHNP DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENBELT RD STE M14
Mailing Address - Street 2:
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2333
Mailing Address - Country:US
Mailing Address - Phone:202-367-3927
Mailing Address - Fax:
Practice Address - Street 1:6201 GREENBELT RD STE M14
Practice Address - Street 2:
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-2333
Practice Address - Country:US
Practice Address - Phone:301-289-7722
Practice Address - Fax:301-441-2518
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2017036463363LF0000X
MDR233930363LP0808X, 363LF0000X
DCRN1035293363LP0808X, 363LP2300X
DC1894374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No374U00000XNursing Service Related ProvidersHome Health Aide