Provider Demographics
NPI:1538475900
Name:FIELDS, KIDADA (MAC)
Entity Type:Individual
Prefix:
First Name:KIDADA
Middle Name:
Last Name:FIELDS
Suffix:
Gender:F
Credentials:MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 PRIOR AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206
Mailing Address - Country:US
Mailing Address - Phone:917-407-3416
Mailing Address - Fax:
Practice Address - Street 1:2435 SAINT PAUL ST
Practice Address - Street 2:C/O KIDADA FIELDS
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5119
Practice Address - Country:US
Practice Address - Phone:917-407-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01827171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist