Healthcare Provider Details

I. General information

NPI: 1629727730
Provider Name (Legal Business Name): RENIE EFUETNGU LEKE TAZISONG PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7067 COLUMBIA GATEWAY DR STE 180
COLUMBIA MD
21046-3408
US

IV. Provider business mailing address

5609 PINE BLUFF CT
FREDERICK MD
21704-6894
US

V. Phone/Fax

Practice location:
  • Phone: 410-929-7225
  • Fax: 443-333-5434
Mailing address:
  • Phone: 240-728-5997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberAC004226
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: