Healthcare Provider Details

I. General information

NPI: 1710477757
Provider Name (Legal Business Name): MARY KOWAL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

4023 9TH ST NE APT 3
WASHINGTON DC
20017-3712
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN1048243
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: