Basic Information
| Provider Information | |||||||||
| NPI: | 1417479395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | JAVONNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4719 QUEENS GROVE ST | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206953483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016383851 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5 GARRETT AVE | ||||||||
| Address2: | |||||||||
| City: | LA PLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206465960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016094000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 07/12/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R189425 | MD | N | Nursing Service Providers | Registered Nurse | 363LF0000X | R-189425 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.