Healthcare Provider Details

I. General information

NPI: 1265735641
Provider Name (Legal Business Name): JENNA MICHONG SONG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7141 SECURITY BLVD
BALTIMORE MD
21244-1811
US

IV. Provider business mailing address

8111 BROOKWOOD FARM RD
FULTON MD
20759-9658
US

V. Phone/Fax

Practice location:
  • Phone: 443-663-6223
  • Fax: 443-663-6131
Mailing address:
  • Phone: 443-663-6223
  • Fax: 443-663-6131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR100864
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: