Provider Demographics
NPI:1376162974
Name:MCCUTCHEN, KHYANNE
Entity Type:Individual
Prefix:
First Name:KHYANNE
Middle Name:
Last Name:MCCUTCHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5018 OLD COURT RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4636
Mailing Address - Country:US
Mailing Address - Phone:443-985-6615
Mailing Address - Fax:
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:443-985-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205120363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily