MEDICARE: IMMACULATE HEALTHCARE SYSTEMS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1033853643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMACULATE HEALTHCARE SYSTEMS LLC

Provider Business Mailing Address
First Line	:	3511 W FOREST PARK AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21216-1428
Country	:	US
Telephone Number	:	254-856-1210
Fax Number	:

Provider Business Practice Location Address
First Line	:	3511 W FOREST PARK AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21216-1428
Country	:	US
Telephone Number	:	443-929-9090
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	STELLA CHINONYEREM NNABUGWU
Credential	:
Telephone Number	:	254-856-1210

Provider Enumeration Date	:	04/21/2022
Last Update Date	:	11/11/2025

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