Provider Demographics
NPI:1023839800
Name:MBAKOP, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MBAKOP
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 1:2803 GRESHAM WAY UNIT 201
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-3939
Mailing Address - Country:US
Mailing Address - Phone:301-674-1332
Mailing Address - Fax:
Practice Address - Street 1:7131 LIBERTY RD STE 100
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-4580
Practice Address - Country:US
Practice Address - Phone:443-200-5338
Practice Address - Fax:443-200-5261
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR235493363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty