Healthcare Provider Details

I. General information

NPI: 1417632571
Provider Name (Legal Business Name): ARTGEVITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1566 HARFORD SQUARE DRIVE
EDGEWOOD MD
21040
US

IV. Provider business mailing address

1566 HARFORD SQUARE DRIVE
EDGEWOOD MD
21040
US

V. Phone/Fax

Practice location:
  • Phone: 410-937-7897
  • Fax:
Mailing address:
  • Phone: 410-937-7897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: NIKIA AYANA EVANS
Title or Position: CEO & OWNER
Credential: MBA
Phone: 410-937-7897