Healthcare Provider Details

I. General information

NPI: 1932768108
Provider Name (Legal Business Name): MRS. JESSICA MARIE PROCTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8118
  • Fax: 240-956-5166
Mailing address:
  • Phone: 301-552-8118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1022412
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR189560
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1022412
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN1022412
License Number StateDC
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR189560
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: