Healthcare Provider Details

I. General information

NPI: 1447678180
Provider Name (Legal Business Name): LILIAN KUSONA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 WHITEHEAD CT
BALTIMORE MD
21207-4037
US

IV. Provider business mailing address

9900 NICOL CT W
BOWIE MD
20721-2960
US

V. Phone/Fax

Practice location:
  • Phone: 443-200-3653
  • Fax:
Mailing address:
  • Phone: 405-239-4663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR244474
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: