Healthcare Provider Details

I. General information

NPI: 1568284008
Provider Name (Legal Business Name): MINDFULVISION PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 N CHARLES ST STE 1904
BALTIMORE MD
21201-3727
US

IV. Provider business mailing address

15 WHEELWRIGHT LN
STAFFORD VA
22554-8833
US

V. Phone/Fax

Practice location:
  • Phone: 307-220-0677
  • Fax:
Mailing address:
  • Phone: 540-698-4259
  • Fax: 540-736-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. TEMILOLUWA O ILESANMI
Title or Position: PRESIDENT
Credential: PMHNP
Phone: 540-698-4259