Healthcare Provider Details

I. General information

NPI: 1356176523
Provider Name (Legal Business Name): MISTY LYNN KOTHARI DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0350
  • Fax:
Mailing address:
  • Phone: 410-933-0000
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR184808
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: