Healthcare Provider Details

I. General information

NPI: 1184674491
Provider Name (Legal Business Name): STEPHANIE M ENTRUP CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W BELVEDERE AVE DEPT OF PEDIATRICS
BALTIMORE MD
21215-5216
US

IV. Provider business mailing address

2401 W BELVEDERE AVE ATTN: CREDENTIALING
BALTIMORE MD
21215-5216
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-8393
  • Fax: 410-601-8390
Mailing address:
  • Phone: 410-601-5524
  • Fax: 410-601-8946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR096361
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberR096361
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR096361
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: