| NPI | 1669254546 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JESSIE COSTLEY Director Of Provider Enrollment 443-839-6928 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family |
| Enumeration Date | 2023-10-16 |
| Last Update Date | 2024-03-20 |