Healthcare Provider Details

I. General information

NPI: 1841990579
Provider Name (Legal Business Name): CARLY HELEN MOMORELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

69 ENGLISH RUN CIR
SPARKS GLENCOE MD
21152-8853
US

V. Phone/Fax

Practice location:
  • Phone: 443-869-0104
  • Fax:
Mailing address:
  • Phone: 443-869-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR220221
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberR220221
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR220221
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: