=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083196414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYLVIE MAH FON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2018
-----------------------------------------------------
Last Update Date | 10/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 N POTOMAC ST STE 103
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21740-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-793-9383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2808 MOZART DR
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-793-9383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R187192
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------