# LEGACY MEDICAL CLINIC WITH MENTAL HEALTH, LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1487272910
- **Authorized official:** CHINASA L NWAULU (CO-OWNER)
- **Authorized official phone:** (301) 880-4900

## Contact information

- **Practice address:** 4700 STAMP RD STE K, TEMPLE HILLS, MD 20748-6717
- **Practice address phone:** (301) 880-4900
- **Mailing address:** 9509 MANOR OAKS VW, UPPER MARLBORO, MD 20772-3192

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LF0000X | Family Nurse Practitioner | — | NULL | — |
| 363LF0000X | Family Nurse Practitioner | — | — | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 07/10/2020
- **Last updated:** 02/13/2024