Healthcare Provider Details

I. General information

NPI: 1417479395
Provider Name (Legal Business Name): JAVONNA O'BRIEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21580 PEABODY ST
LEONARDTOWN MD
20650-2962
US

IV. Provider business mailing address

21580 PEABODY ST
LEONARDTOWN MD
20650-2962
US

V. Phone/Fax

Practice location:
  • Phone: 301-475-4330
  • Fax: 301-475-4350
Mailing address:
  • Phone: 301-475-4330
  • Fax: 301-475-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR-189425
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR189425
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: