Provider Demographics
NPI:1841929205
Name:EGWUATU, GLADYS EBELE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:EBELE
Last Name:EGWUATU
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 MANOR GATE TER
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-8516
Mailing Address - Country:US
Mailing Address - Phone:240-636-3511
Mailing Address - Fax:
Practice Address - Street 1:10903 INDIAN HEAD HWY STE 505
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4012
Practice Address - Country:US
Practice Address - Phone:240-467-0628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN67786363LP0808X
MDR143400363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2022006900OtherAMERICAN NURSES CREDENTIALING CENTER VERIFICATION CERTIFICATE
MD052524300Medicaid