=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356218218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCE GEORGE'S COUNTY HEALTH DEPARTMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2025
-----------------------------------------------------
Last Update Date | 12/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 REDLEAF ROSE CT
-----------------------------------------------------
City | REISTERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21136-6046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-883-7879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 MCCORMICK DR
-----------------------------------------------------
City | LARGO
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20774-5329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | TAMALA VICKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-302-8576
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------