Basic Information
| Provider Information | |||||||||
| NPI: | 1497192751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SILVA | ||||||||
| FirstName: | KEYONNA | ||||||||
| MiddleName: | NICKARA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL RD | ||||||||
| Address2: | ATT: CONTRACT & CREDENTIALING COORD. | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104144791 | ||||||||
| FaxNumber: | 4104144558 | ||||||||
| Practice Location | |||||||||
| Address1: | 14090 HG TRUEMAN RD | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | SOLOMONS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206883151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103943712 | ||||||||
| FaxNumber: | 4103943714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OT015019 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | H0081227 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110222200 | 05 | MD | MEDICAID |