Provider Demographics
NPI:1689911075
Name:OLUMBA, AMAECHI IMELDA
Entity Type:Individual
Prefix:MRS
First Name:AMAECHI
Middle Name:IMELDA
Last Name:OLUMBA
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 1:12311 GUINEVERE RD
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-8939
Mailing Address - Country:US
Mailing Address - Phone:202-403-9934
Mailing Address - Fax:
Practice Address - Street 1:920 BELLEVUE ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-6030
Practice Address - Country:US
Practice Address - Phone:202-562-4939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1051589163W00000X
DCNP1051589363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse