MEDICARE: RFOM NURSE PRACTITIONER CLINIC, 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	363LA2200X	Adult Health Nurse Practitioner	R161889	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669723961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RFOM NURSE PRACTITIONER CLINIC, LLC

Provider Business Mailing Address
First Line	:	9656 BRASSIE WAY
Second Line	:
City	:	MONTGOMERY VILLAGE
State	:	MD
Zip	:	20886-1910
Country	:	US
Telephone Number	:	240-447-3204
Fax Number	:	301-587-3204

Provider Business Practice Location Address
First Line	:	8238 GEORGIA AVE
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-4516
Country	:	US
Telephone Number	:	240-447-3204
Fax Number	:	301-587-3204

Authorized Official
Title or Position	:	CEO
Name	:	STELLA K JEFFERIES
Credential	:	CRNP
Telephone Number	:	240-447-3204

Provider Enumeration Date	:	09/26/2012
Last Update Date	:	09/26/2012

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