Provider Demographics
NPI:1689412843
Name:DOUGLAS, NEVYLL N
Entity type:Individual
Prefix:
First Name:NEVYLL
Middle Name:N
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9841 WASHINGTONIAN BLVD STE 2001067
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-5389
Mailing Address - Country:US
Mailing Address - Phone:240-583-0207
Mailing Address - Fax:
Practice Address - Street 1:9841 WASHINGTONIAN BLVD STE 2001067
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-5389
Practice Address - Country:US
Practice Address - Phone:240-583-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0629363LC1500X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health