Provider Demographics
NPI:1336624113
Name:OPTIMUM FAMILY CLINIC
Entity Type:Organization
Organization Name:OPTIMUM FAMILY CLINIC
Other - Org Name:OPTIMUM FAMILY CLINIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BLESSING
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:703-436-1823
Mailing Address - Street 1:6014 HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-1327
Mailing Address - Country:US
Mailing Address - Phone:443-985-6011
Mailing Address - Fax:866-596-1084
Practice Address - Street 1:6014 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1327
Practice Address - Country:US
Practice Address - Phone:443-985-6011
Practice Address - Fax:866-596-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR198392OtherMARYLAND LICENSE