Healthcare Provider Details

I. General information

NPI: 1134089865
Provider Name (Legal Business Name): IESHA HAUGHTON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 BALTIMORE ANNAPOLIS BLVD
GLEN BURNIE MD
21061-1431
US

IV. Provider business mailing address

7095 BALTIMORE ANNAPOLIS BLVD
GLEN BURNIE MD
21061-1431
US

V. Phone/Fax

Practice location:
  • Phone: 410-859-3113
  • Fax: 410-859-1006
Mailing address:
  • Phone: 410-859-3113
  • Fax: 410-859-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR239391
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: