Provider Demographics
NPI:1215682661
Name:MI-REKA, MARYN
Entity type:Individual
Prefix:
First Name:MARYN
Middle Name:
Last Name:MI-REKA
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 1:4501 VALIANT TRCE APT SUITE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4678
Mailing Address - Country:US
Mailing Address - Phone:240-252-0588
Mailing Address - Fax:
Practice Address - Street 1:12200 ANNAPOLIS RD STE 123
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9182
Practice Address - Country:US
Practice Address - Phone:301-552-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001254715363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily