Healthcare Provider Details

I. General information

NPI: 1639754336
Provider Name (Legal Business Name): MILDRED E KANGKOLO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2021
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 ELKRIDGE LANDING RD STE 300
LINTHICUM HEIGHTS MD
21090-2958
US

IV. Provider business mailing address

785 ELKRIDGE LANDING RD STE 300
LINTHICUM HEIGHTS MD
21090-2958
US

V. Phone/Fax

Practice location:
  • Phone: 443-548-5700
  • Fax:
Mailing address:
  • Phone: 410-548-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR192423
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: