Provider Demographics
NPI:1609368752
Name:ACKOM, ROBERTA Y (CNM)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:Y
Last Name:ACKOM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 CROSSROADS CIR UNIT 328
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2965
Mailing Address - Country:US
Mailing Address - Phone:301-275-9459
Mailing Address - Fax:
Practice Address - Street 1:9000 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3901
Practice Address - Country:US
Practice Address - Phone:443-777-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202083367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife