Healthcare Provider Details

I. General information

NPI: 1962279455
Provider Name (Legal Business Name): EXCLUSIV NP CONCIERGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5457 TWIN KNOLLS RD STE 300
COLUMBIA MD
21045-3296
US

IV. Provider business mailing address

5457 TWIN KNOLLS RD STE 300
COLUMBIA MD
21045-3296
US

V. Phone/Fax

Practice location:
  • Phone: 980-370-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TASHANA JOHNSON
Title or Position: OWNER
Credential: CRNP
Phone: 980-370-4400