Healthcare Provider Details

I. General information

NPI: 1639936446
Provider Name (Legal Business Name): TARA WEINKAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 LINDEN AVE STE B
BALTIMORE MD
21201-4606
US

IV. Provider business mailing address

PO BOX 69043
BALTIMORE MD
21264-9043
US

V. Phone/Fax

Practice location:
  • Phone: 410-225-8240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR158786
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: