Healthcare Provider Details

I. General information

NPI: 1619616760
Provider Name (Legal Business Name): TOLLER ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/27/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2439 E LAFAYETTE AVE
BALTIMORE MD
21213-2562
US

IV. Provider business mailing address

2439 E LAFAYETTE AVE
BALTIMORE MD
21213-2562
US

V. Phone/Fax

Practice location:
  • Phone: 443-868-4107
  • Fax: 443-885-9778
Mailing address:
  • Phone: 443-868-4107
  • Fax: 443-885-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WALTER LEWIS TOLLER
Title or Position: OWNER OF ENTITY
Credential:
Phone: 443-868-4107