Healthcare Provider Details

I. General information

NPI: 1366120495
Provider Name (Legal Business Name): KADDIE KALLON NURSING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 EVARTS ST NE
WASHINGTON DC
20018-2017
US

IV. Provider business mailing address

1503 EVARTS ST NE
WASHINGTON DC
20018-2017
US

V. Phone/Fax

Practice location:
  • Phone: 240-899-2928
  • Fax: 240-451-1080
Mailing address:
  • Phone: 240-899-2928
  • Fax: 240-451-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KADDIE KALLON
Title or Position: CEO
Credential: NP
Phone: 240-899-2928