1124423090 NPI number — JANENE MICHELLE LEVY

Table of content: JANENE MICHELLE LEVY (NPI 1124423090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124423090 NPI number — JANENE MICHELLE LEVY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEVY
Provider First Name:
JANENE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEVY-STILL
Provider Other First Name:
JANENE
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1124423090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1632 HARTSDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21239-3605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-802-7892
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6801 BELAIR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21206-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-372-7890
Provider Business Practice Location Address Fax Number:
855-714-2796
Provider Enumeration Date:
11/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R144895 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 723008700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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