Healthcare Provider Details

I. General information

NPI: 1619517851
Provider Name (Legal Business Name): KIERRA ROYSTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N HOWARD ST
BALTIMORE MD
21218-5909
US

IV. Provider business mailing address

2812 CRESTWICK PL
DISTRICT HEIGHTS MD
20747-2784
US

V. Phone/Fax

Practice location:
  • Phone: 301-792-4607
  • Fax:
Mailing address:
  • Phone: 301-792-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number422660
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number28255
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number422660
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number422660
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: