Provider Demographics
NPI:1619517851
Name:ROYSTER, KIERRA
Entity Type:Individual
Prefix:
First Name:KIERRA
Middle Name:
Last Name:ROYSTER
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 1:2812 CRESTWICK PL
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-2784
Mailing Address - Country:US
Mailing Address - Phone:301-792-4607
Mailing Address - Fax:
Practice Address - Street 1:1900 N HOWARD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5909
Practice Address - Country:US
Practice Address - Phone:301-792-4607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD422660174400000X, 224P00000X, 332B00000X
MD28255104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No174400000XOther Service ProvidersSpecialist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies