Healthcare Provider Details

I. General information

NPI: 1841408697
Provider Name (Legal Business Name): ETTIENNE'S PREMIER PEDIATRIC CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 MITCHELLVILLE RD STE 115
BOWIE MD
20716-1385
US

IV. Provider business mailing address

2905 MITCHELLVILLE RD STE 115
BOWIE MD
20716-1385
US

V. Phone/Fax

Practice location:
  • Phone: 301-390-7960
  • Fax: 301-218-2800
Mailing address:
  • Phone: 301-390-7960
  • Fax: 301-218-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0046373
License Number StateMD

VIII. Authorized Official

Name: SUZETTE SCIPIO ETTIENNE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 301-390-7960