Healthcare Provider Details

I. General information

NPI: 1053566406
Provider Name (Legal Business Name): MARTHA DEBORAH ROSE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2008
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 23RD ST NW
WASHINGTON DC
20037-2342
US

IV. Provider business mailing address

20416 BLOOMINGVILLE CT
GERMANTOWN MD
20876-5648
US

V. Phone/Fax

Practice location:
  • Phone: 202-715-4000
  • Fax:
Mailing address:
  • Phone: 301-540-8647
  • Fax: 301-540-8647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR116317
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN40365
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: