Healthcare Provider Details

I. General information

NPI: 1396963609
Provider Name (Legal Business Name): MARY KATHERINE GAST CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21748 ROTH AVE
GEORGETOWN DE
19947-3239
US

IV. Provider business mailing address

1601 KIRKWOOD HWY
WILMINGTON DE
19805-4917
US

V. Phone/Fax

Practice location:
  • Phone: 800-461-8262
  • Fax: 302-633-5379
Mailing address:
  • Phone: 800-461-8262
  • Fax: 302-633-5379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberLP-0010565
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR157914
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: