Provider Demographics
NPI:1487265864
Name:IDIKA, ATOLA NNENNA
Entity type:Individual
Prefix:
First Name:ATOLA
Middle Name:NNENNA
Last Name:IDIKA
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 1:1316 MINNESOTA WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-6060
Mailing Address - Country:US
Mailing Address - Phone:202-702-6789
Mailing Address - Fax:
Practice Address - Street 1:9470 ANNAPOLIS RD STE 101
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4048
Practice Address - Country:US
Practice Address - Phone:301-803-5833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR210401363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD05211985Medicaid