Healthcare Provider Details

I. General information

NPI: 1760843049
Provider Name (Legal Business Name): MIN JEONG JEON CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 OLD WASHINGTON RD SUITE 101
WALDORF MD
20602-3224
US

IV. Provider business mailing address

3500 OLD WASHINGTON RD SUITE 101
WALDORF MD
20602-3224
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-1133
  • Fax:
Mailing address:
  • Phone: 301-645-1133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR212891
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR212891
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.401394
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: