Provider Demographics
NPI:1972173904
Name:AVWONTOM, NGUM (FNP, CRNP)
Entity Type:Individual
Prefix:MS
First Name:NGUM
Middle Name:
Last Name:AVWONTOM
Suffix:
Gender:F
Credentials:FNP, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6614 WINDSOR MILL RD
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5381
Mailing Address - Country:US
Mailing Address - Phone:301-404-1989
Mailing Address - Fax:
Practice Address - Street 1:5400 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5100
Practice Address - Country:US
Practice Address - Phone:301-404-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR213556363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care