=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790030500
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAMALA DJUANA VIA NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2012
-----------------------------------------------------
Last Update Date | 07/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5601 LOCH RAVEN BLVD SUITE 406
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21239-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-444-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5601 LOCH RAVEN BLVD SUITE 406
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21239-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-444-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R151745
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------