Healthcare Provider Details

I. General information

NPI: 1902596745
Provider Name (Legal Business Name): NORAH JEMUTAI TIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 VALENTINE WAY
HANOVER MD
21076-2363
US

IV. Provider business mailing address

6011 VALENTINE WAY
HANOVER MD
21076-2363
US

V. Phone/Fax

Practice location:
  • Phone: 952-992-9162
  • Fax:
Mailing address:
  • Phone: 952-992-9162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAC005449
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: