Healthcare Provider Details

I. General information

NPI: 1033853643
Provider Name (Legal Business Name): IMMACULATE HEALTHCARE SYSTEMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 W FOREST PARK AVE
BALTIMORE MD
21216-1428
US

IV. Provider business mailing address

3511 W FOREST PARK AVE
BALTIMORE MD
21216-1428
US

V. Phone/Fax

Practice location:
  • Phone: 443-929-9090
  • Fax:
Mailing address:
  • Phone: 254-856-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STELLA CHINONYEREM NNABUGWU
Title or Position: CEO
Credential:
Phone: 254-856-1210