Provider Demographics
NPI:1821628801
Name:FAMILYCARE NURSE PRACTITIONER LLC
Entity Type:Organization
Organization Name:FAMILYCARE NURSE PRACTITIONER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NGWANMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NWOKORO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-945-2289
Mailing Address - Street 1:2300 GARRISON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2308
Mailing Address - Country:US
Mailing Address - Phone:410-945-2289
Mailing Address - Fax:410-945-4255
Practice Address - Street 1:2300 GARRISON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2308
Practice Address - Country:US
Practice Address - Phone:410-945-2289
Practice Address - Fax:410-945-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD772050500Medicaid