Healthcare Provider Details

I. General information

NPI: 1568375822
Provider Name (Legal Business Name): BLOSSOM PRIMARY CARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3849 PENNSYLVANIA AVE SE
WASHINGTON DC
20020-1309
US

IV. Provider business mailing address

12113 SAND WEDGE LN
UPPER MARLBORO MD
20772-7973
US

V. Phone/Fax

Practice location:
  • Phone: 240-645-7616
  • Fax:
Mailing address:
  • Phone: 240-645-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ODELLE TSAYA KAMANI
Title or Position: OWNER
Credential: PMHNP
Phone: 240-645-7616