MEDICARE: IMANI HOUSE MEDICAL SERVICES

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

General Provider Information

NPI Number	:	1184233595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMANI HOUSE MEDICAL SERVICES

Provider Business Mailing Address
First Line	:	6101 PARK HEIGHTS AVE APT 1D
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-3640
Country	:	US
Telephone Number	:	410-624-7190
Fax Number	:	410-624-7193

Provider Business Practice Location Address
First Line	:	6101 PARK HEIGHTS AVE APT 1D
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-3640
Country	:	US
Telephone Number	:	410-624-7190
Fax Number	:	410-624-7193

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	ANNETTE YOUVONNE KINGEL
Credential	:	DR.
Telephone Number	:	410-624-7190

Provider Enumeration Date	:	07/31/2020
Last Update Date	:	07/31/2020

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Directions to “IMANI HOUSE MEDICAL SERVICES ” Practice Location

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