Healthcare Provider Details

I. General information

NPI: 1053172601
Provider Name (Legal Business Name): STEPHANIE BLADEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 06/27/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY
ANNAPOLIS MD
21401-3742
US

IV. Provider business mailing address

2309 MOUNT TABOR RD
GAMBRILLS MD
21054-1839
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-9700
  • Fax:
Mailing address:
  • Phone: 410-458-4104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR220671
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: