MEDICARE: NIKISHA LASHAWN FAUNTLEROY

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1528787892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKISHA LASHAWN FAUNTLEROY

Provider Business Mailing Address
First Line	:	1937 BROOKS DR
Second Line	:
City	:	CAPITOL HEIGHTS
State	:	MD
Zip	:	20743-5537
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1937 BROOKS DR
Second Line	:
City	:	CAPITOL HEIGHTS
State	:	MD
Zip	:	20743-5537
Country	:	US
Telephone Number	:	202-794-2149
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	08/22/2022

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