=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063298008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHALANIS KURE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2023
-----------------------------------------------------
Last Update Date | 01/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1718 BELMONT AVE STE D
-----------------------------------------------------
City | WINDSOR MILL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21244-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-943-0892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 833 CHAUNCEY AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21217-4652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-943-0892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | IMANI V BRYAN
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 617-943-0892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------