Provider Demographics
NPI:1962965574
Name:AKPORUBARE, IRENE OMOTEJOWHO
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:OMOTEJOWHO
Last Name:AKPORUBARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:O
Other - Last Name:GOLD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1805 FOXWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-4141
Mailing Address - Country:US
Mailing Address - Phone:404-789-6482
Mailing Address - Fax:
Practice Address - Street 1:1805 FOXWOOD CIR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-4141
Practice Address - Country:US
Practice Address - Phone:404-789-6482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13751374U00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide