Healthcare Provider Details

I. General information

NPI: 1376162974
Provider Name (Legal Business Name): KHYANNE MCCUTCHEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GARRISON BLVD
BALTIMORE MD
21216-2335
US

IV. Provider business mailing address

5018 OLD COURT RD
RANDALLSTOWN MD
21133-4636
US

V. Phone/Fax

Practice location:
  • Phone: 443-985-6616
  • Fax:
Mailing address:
  • Phone: 443-985-6615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR205120
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: