=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639005267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMETHEAN HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2026
-----------------------------------------------------
Last Update Date | 06/22/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6609 FAIRMOUNT AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215-1906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-861-2531
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1019 MIDLAND AVE
-----------------------------------------------------
City | YORK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17403-3339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER / OWNER
-----------------------------------------------------
Name | KISUN PETERS-DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-861-2531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------