Healthcare Provider Details

I. General information

NPI: 1124693015
Provider Name (Legal Business Name): MINDFUL MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7404 EXECUTIVE PL STE 100
LANHAM MD
20706-6237
US

IV. Provider business mailing address

7404 EXECUTIVE PLACE STE 100
LANHAM MD
20706
US

V. Phone/Fax

Practice location:
  • Phone: 443-379-4410
  • Fax:
Mailing address:
  • Phone: 443-379-4410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRISHA-LEIGH PORTER
Title or Position: OWNER/NP
Credential: CRNP
Phone: 443-379-4410