Basic Information
| Provider Information | |||||||||
| NPI: | 1518511054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGUZO | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | CHIJIOKE | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9877 DECATUR RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLE RIVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212203776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4433702946 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9000 FRANKLIN SQUARE DR | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212373901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437777000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2019 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R203991 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 256021600 | 05 | MD | MEDICAID |