Healthcare Provider Details

I. General information

NPI: 1790030989
Provider Name (Legal Business Name): JENNIFER ANNE GHADISHA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY SUITE 306
ANNAPOLIS MD
21401-3742
US

IV. Provider business mailing address

2000 MEDICAL PKWY SUITE 306
ANNAPOLIS MD
21401-3742
US

V. Phone/Fax

Practice location:
  • Phone: 410-571-9700
  • Fax: 470-571-9710
Mailing address:
  • Phone: 410-571-9700
  • Fax: 470-571-9710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPN001403
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR158431
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: