Healthcare Provider Details

I. General information

NPI: 1114511797
Provider Name (Legal Business Name): NINNA NANA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 09/20/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

804 LANDMARK DR STE 118
GLEN BURNIE MD
21061-4486
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-1358
  • Fax: 410-328-1897
Mailing address:
  • Phone: 410-863-4899
  • Fax: 443-873-2454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC08151
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: