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General NPI Number Information
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NPI Number | 1720800600
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Entity Type | Individual
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Provider Name | TYEISHA WILKINS WITHERSPOON AGPCNP
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Gender | Female
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Dates
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Enumeration Date | 10/30/2024
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | 4801 DORSEY HALL DR STE 226
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City | ELLICOTT CITY
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State | MD
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Zip | 21042-7764
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Country | US
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Telephone | 410-997-7660
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Fax |
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Provider Business Mailing Address
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Address Line | 3205 GRANITE RD
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City | WOODSTOCK
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State | MD
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Zip | 21163-1005
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Country | US
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Telephone | 410-493-0125
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | R223487
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | R223487
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | R223487
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License Number State | MD
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