Provider Demographics
NPI:1538734579
Name:BWETE-MUGYENZI, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:BWETE-MUGYENZI
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 1:11306 WILDMEADOWS ST
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2684
Mailing Address - Country:US
Mailing Address - Phone:301-769-1027
Mailing Address - Fax:
Practice Address - Street 1:4200 ALTAMONT PL
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3052
Practice Address - Country:US
Practice Address - Phone:301-645-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202575363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily