Healthcare Provider Details

I. General information

NPI: 1952934671
Provider Name (Legal Business Name): ADVANCE INTEGRATED HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16204 PENTERRA WAY
BOWIE MD
20716-1919
US

IV. Provider business mailing address

16204 PENTERRA WAY
BOWIE MD
20716-1919
US

V. Phone/Fax

Practice location:
  • Phone: 301-978-1990
  • Fax:
Mailing address:
  • Phone: 301-978-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DEBORAH KESEWAH KOROMA
Title or Position: NURSE PRACTITIONER
Credential: CRNP
Phone: 301-978-1990