Provider Demographics
NPI:1407583362
Name:STEPHENS, KISHMA K (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KISHMA
Middle Name:K
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6622B RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-2317
Mailing Address - Country:US
Mailing Address - Phone:240-330-0146
Mailing Address - Fax:
Practice Address - Street 1:6622B RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2317
Practice Address - Country:US
Practice Address - Phone:413-912-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202637363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics