Provider Demographics
NPI:1447519004
Name:IGWACHO, BERENICE
Entity type:Individual
Prefix:
First Name:BERENICE
Middle Name:
Last Name:IGWACHO
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 1:11801 MEADOWLAND DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11801 MEADOWLAND DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720
Practice Address - Country:US
Practice Address - Phone:240-643-9673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0113334163WH0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty