Healthcare Provider Details

I. General information

NPI: 1235470147
Provider Name (Legal Business Name): THERESA RUGALLA BOOKER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA RUGALLA CRNP

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

8518 79TH DIVISION BLVD
FORT MEADE MD
20755-1507
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-9227
  • Fax:
Mailing address:
  • Phone: 717-512-8765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP012500
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR184354
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: