Healthcare Provider Details

I. General information

NPI: 1427244706
Provider Name (Legal Business Name): COPPIN STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W NORTH AVE SUITE 131
BALTIMORE MD
21216-3633
US

IV. Provider business mailing address

2601 W. NORTH AVENUE SUITE 131
BALTIMORE MD
21216
US

V. Phone/Fax

Practice location:
  • Phone: 410-951-4188
  • Fax:
Mailing address:
  • Phone: 410-951-4188
  • Fax: 410-951-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateMD

VIII. Authorized Official

Name: MRS. SHAVON T. LEGETTE
Title or Position: ASSOCIATE DIRECTOR
Credential: CRNP
Phone: 410-951-4188