Healthcare Provider Details

I. General information

NPI: 1760995021
Provider Name (Legal Business Name): SIYAMI EGBASE TAKHA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12070 OLD LINE CTR STE 211
SAINT CHARLES MD
20602-2567
US

IV. Provider business mailing address

12070 OLD LINE CTR STE 211
SAINT CHARLES MD
20602-2567
US

V. Phone/Fax

Practice location:
  • Phone: 202-600-6748
  • Fax: 800-521-0943
Mailing address:
  • Phone: 202-600-6748
  • Fax: 800-521-0943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR194882
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR194882
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: