Healthcare Provider Details

I. General information

NPI: 1891681417
Provider Name (Legal Business Name): JEREMIAH CREDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N WOLFE ST
BALTIMORE MD
21205-2110
US

IV. Provider business mailing address

300 W REDWOOD ST APT 1140
BALTIMORE MD
21201-2360
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-4766
  • Fax:
Mailing address:
  • Phone: 909-641-5025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95273477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: