Healthcare Provider Details

I. General information

NPI: 1659162402
Provider Name (Legal Business Name): EVERGREEN HEALTHCARE CLINIC LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N CHARLES ST STE D
BALTIMORE MD
21201-4305
US

IV. Provider business mailing address

13707 CROWNSGATE WAY
GERMANTOWN MD
20874-4424
US

V. Phone/Fax

Practice location:
  • Phone: 240-644-5570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: YVETTE LEDJO
Title or Position: CEO
Credential:
Phone: 240-644-5570