Provider Demographics
NPI:1790549772
Name:CHONCHORO, MARTHA TADESSE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:TADESSE
Last Name:CHONCHORO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18842 BROKEN OAK RD
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841-4222
Mailing Address - Country:US
Mailing Address - Phone:301-222-7604
Mailing Address - Fax:
Practice Address - Street 1:18842 BROKEN OAK RD
Practice Address - Street 2:
Practice Address - City:BOYDS
Practice Address - State:MD
Practice Address - Zip Code:20841-4222
Practice Address - Country:US
Practice Address - Phone:301-222-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212474363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health