Provider Demographics
NPI:1356061717
Name:EZENWAKA, MIRIAM CHYNWE
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:CHYNWE
Last Name:EZENWAKA
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 1:4106 WINDING WATERS TER
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-2504
Mailing Address - Country:US
Mailing Address - Phone:301-675-5364
Mailing Address - Fax:
Practice Address - Street 1:1221 TAYLOR ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5617
Practice Address - Country:US
Practice Address - Phone:202-464-9200
Practice Address - Fax:202-291-2160
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR172386363LP0808X
DCNP500015019363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health