Basic Information
| Provider Information | |||||||||
| NPI: | 1720172547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KYEREMATEN | ||||||||
| FirstName: | SOPHIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOETENG | ||||||||
| OtherFirstName: | SOPHIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3001 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | CHEVERLY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207851189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016182355 | ||||||||
| FaxNumber: | 3016183521 | ||||||||
| Practice Location | |||||||||
| Address1: | 7582 ANNAPOLIS RD | ||||||||
| Address2: | |||||||||
| City: | HYATTSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207841744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016181550 | ||||||||
| FaxNumber: | 3014291873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | R116128 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 420000213 | 05 | MD | MEDICAID |