Provider Demographics
NPI:1609318054
Name:COMMUNITY WELLNESS AND OCCUPATIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:COMMUNITY WELLNESS AND OCCUPATIONAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:MINNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NDEM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-709-8471
Mailing Address - Street 1:9808 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2007
Mailing Address - Country:US
Mailing Address - Phone:410-709-8471
Mailing Address - Fax:
Practice Address - Street 1:9808 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2007
Practice Address - Country:US
Practice Address - Phone:410-709-8471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR132005363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty