Basic Information
Provider Information | |||||||||
NPI: | 1194361055 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WORKMAN | ||||||||
FirstName: | JUSTINA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STEVENS | ||||||||
OtherFirstName: | JUSTINA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1125 DIAMOND DR | ||||||||
Address2: | STE B | ||||||||
City: | HAGERSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 217405857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017901482 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1125 DIAMOND DR | ||||||||
Address2: |   | ||||||||
City: | HAGERSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 217405857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3017901482 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/25/2019 | ||||||||
LastUpdateDate: | 01/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R160986 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.