=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275378895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALCYON COMPREHENSIVE HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2024
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BANNING ST STE 270
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19904-3489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-724-6157
-----------------------------------------------------
Fax | 302-480-1564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 82 SILVER LEAF LN
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19901-3270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-724-6157
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIMBERLY FORD
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 302-724-6157
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------