Healthcare Provider Details

I. General information

NPI: 1306067319
Provider Name (Legal Business Name): JEAN MARIE PRESTON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910AQUAHART RD. 3RD FLOOR
GLEN BURNIE MD
21061
US

IV. Provider business mailing address

3430 BLANDFORD WAY
DAVIDSONVILLE MD
21035
US

V. Phone/Fax

Practice location:
  • Phone: 410-222-6838
  • Fax: 410-222-6840
Mailing address:
  • Phone: 410-956-5564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP21570
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: