Provider Demographics
NPI:1801402508
Name:BEN-AGU, CATHERINE NKEIRUKA
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:NKEIRUKA
Last Name:BEN-AGU
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 1:5656 LIBERTY MANOR CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-3279
Mailing Address - Country:US
Mailing Address - Phone:571-505-1775
Mailing Address - Fax:
Practice Address - Street 1:604 S FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1275
Practice Address - Country:US
Practice Address - Phone:571-505-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180109363LP0808X
MDAC003547363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty