Healthcare Provider Details

I. General information

NPI: 1275233512
Provider Name (Legal Business Name): WOMEN'S WELLNESS LOUNGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N HOWARD ST
BALTIMORE MD
21201-3641
US

IV. Provider business mailing address

415 N HOWARD ST
BALTIMORE MD
21201-3641
US

V. Phone/Fax

Practice location:
  • Phone: 443-303-6732
  • Fax:
Mailing address:
  • Phone: 443-303-6732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DELAYNA KELLER
Title or Position: OWNER
Credential: RN
Phone: 443-303-6732