Provider Demographics
NPI:1508827809
Name:BANGNAM, BERNADETTE ASSUMPTA (FNP, WHNP)
Entity Type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:ASSUMPTA
Last Name:BANGNAM
Suffix:
Gender:F
Credentials:FNP, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 GLADYS FARM WAY # A
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20882-1421
Mailing Address - Country:US
Mailing Address - Phone:240-437-9828
Mailing Address - Fax:
Practice Address - Street 1:6305 IVY LN STE 101
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-6326
Practice Address - Country:US
Practice Address - Phone:301-235-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX458639163WW0101X
MDR221746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAND1-0429-8160Medicare UPIN
CA10620Medicare UPIN