Healthcare Provider Details

I. General information

NPI: 1013876879
Provider Name (Legal Business Name): HEALTHSPAN COMPREHENSIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5502 EDMONDSON AVE
BALTIMORE MD
21229-2220
US

IV. Provider business mailing address

4380B MONTGOMERY RD # 1051
ELLICOTT CITY MD
21043-6006
US

V. Phone/Fax

Practice location:
  • Phone: 410-988-4418
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PETERSON NGUYEN
Title or Position: OWNER
Credential: PMHNP, CRNP
Phone: 410-988-4418