Healthcare Provider Details

I. General information

NPI: 1275119232
Provider Name (Legal Business Name): KEISHA SEREEN PARKE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 RACE ROAD STE 403
ROSEDALE MD
21237-2123
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 443-868-7101
  • Fax: 443-732-0054
Mailing address:
  • Phone: 410-933-6423
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR166453
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: