=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548259757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE KIDZ NP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6490 LANDOVER RD SUITE H
-----------------------------------------------------
City | CHEVERLY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-322-1696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6490 LANDOVER RD SUITE H
-----------------------------------------------------
City | CHEVERLY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-322-1696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. CAROL LISHA WHITTINGTON-WASHINGTON
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 301-322-1696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | R094051
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------