Healthcare Provider Details

I. General information

NPI: 1770038887
Provider Name (Legal Business Name): PROMENADE PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SANGAMORE RD SUITE S207
BETHESDA MD
20816-2508
US

IV. Provider business mailing address

955 LENFANT PLZ SW SUITE 325
WASHINGTON DC
20024-2119
US

V. Phone/Fax

Practice location:
  • Phone: 202-684-7167
  • Fax:
Mailing address:
  • Phone: 202-684-7167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLY GOODMAN
Title or Position: OWNER
Credential: NP
Phone: 202-684-7167