Provider Demographics
NPI:1922664796
Name:OTUGO, MARYROSE
Entity Type:Individual
Prefix:MRS
First Name:MARYROSE
Middle Name:
Last Name:OTUGO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARYROSE
Other - Middle Name:
Other - Last Name:OTUGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP-PMH
Mailing Address - Street 1:14301 WILSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-9512
Mailing Address - Country:US
Mailing Address - Phone:301-256-5504
Mailing Address - Fax:
Practice Address - Street 1:14301 WILSHIRE CT
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-9512
Practice Address - Country:US
Practice Address - Phone:301-256-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR168375363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health