Healthcare Provider Details

I. General information

NPI: 1023908639
Provider Name (Legal Business Name): EVITA THOMPSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 EDMONDSON AVE
BALTIMORE MD
21229-1807
US

IV. Provider business mailing address

4118 EDMONDSON AVE
BALTIMORE MD
21229-1807
US

V. Phone/Fax

Practice location:
  • Phone: 443-570-6550
  • Fax: 443-570-6550
Mailing address:
  • Phone: 443-570-6550
  • Fax: 443-570-6550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR122441
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR122441
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: