MEDICARE: MR. IMMANUEL VAN SLYKE JOSEPH RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	R180947	MD

General Provider Information

NPI Number	:	1932975638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. IMMANUEL VAN SLYKE JOSEPH RN

Provider Business Mailing Address
First Line	:	8811 SUMNER GROVE DR
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20708-3533
Country	:	US
Telephone Number	:	240-355-3266
Fax Number	:

Provider Business Practice Location Address
First Line	:	8811 SUMNER GROVE DR
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20708-3533
Country	:	US
Telephone Number	:	240-355-3266
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2023
Last Update Date	:	12/04/2023

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