Healthcare Provider Details

I. General information

NPI: 1912515008
Provider Name (Legal Business Name): CHASE BREXTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SECURITY BLVD STE 200
BALTIMORE MD
21244-2412
US

IV. Provider business mailing address

8604 BRIARWOOD CT
LAUREL MD
20708-1320
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-2050
  • Fax:
Mailing address:
  • Phone: 301-256-7200
  • Fax:

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: VIVIANE FLORA DICOUM
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 301-256-7200