Healthcare Provider Details

I. General information

NPI: 1447459854
Provider Name (Legal Business Name): RAFAEL J NOLLIE CSA/LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3470 OLNEY LAYTONSVILLE RD SUITE 182
OLNEY MD
20832-1734
US

IV. Provider business mailing address

3470 OLNEY LAYTONSVILLE RD SUITE 182
OLNEY MD
20832-1734
US

V. Phone/Fax

Practice location:
  • Phone: 301-363-4934
  • Fax:
Mailing address:
  • Phone: 972-363-8198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP49426
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number3077
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: