Provider Demographics
NPI:1831567890
Name:ZZIWA ADULT CLINICAL PRACTICE PC
Entity type:Organization
Organization Name:ZZIWA ADULT CLINICAL PRACTICE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:IRYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZZIWA-KABENGE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, CRNP
Authorized Official - Phone:443-522-0383
Mailing Address - Street 1:4404 WYNFIELD DR
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-7141
Mailing Address - Country:US
Mailing Address - Phone:443-522-0383
Mailing Address - Fax:443-836-2415
Practice Address - Street 1:4404 WYNFIELD DR
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-7141
Practice Address - Country:US
Practice Address - Phone:443-522-0383
Practice Address - Fax:443-836-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR133308261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD049292200Medicaid
MD231502YXUOtherMEDICARE