MEDICARE: MRS. MARY GRACE LEGASPI WILD MSN, RN, AGPCNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	R164664	MD

General Provider Information

NPI Number	:	1528927647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY GRACE LEGASPI WILD MSN, RN, AGPCNP-BC

Provider Business Mailing Address
First Line	:	4335 SLATER AVE
Second Line	:
City	:	NOTTINGHAM
State	:	MD
Zip	:	21236-2725
Country	:	US
Telephone Number	:	301-805-7084
Fax Number	:

Provider Business Practice Location Address
First Line	:	12200 ANNAPOLIS RD STE 115
Second Line	:
City	:	GLENN DALE
State	:	MD
Zip	:	20769-9182
Country	:	US
Telephone Number	:	301-805-7084
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2026
Last Update Date	:	01/16/2026

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