Provider Demographics
NPI:1255970380
Name:EBONGUE, JULIENNE
Entity type:Individual
Prefix:
First Name:JULIENNE
Middle Name:
Last Name:EBONGUE
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 1:3010 MARSH CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2972
Mailing Address - Country:US
Mailing Address - Phone:240-604-2878
Mailing Address - Fax:
Practice Address - Street 1:10313 GEORGIA AVE STE 307
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-5006
Practice Address - Country:US
Practice Address - Phone:301-754-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily