Healthcare Provider Details

I. General information

NPI: 1740046044
Provider Name (Legal Business Name): JACQUELYN CRUZ QUILAO BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELYN REYNALDO CRUZ BSN,RN

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N GREENE ST
BALTIMORE MD
21201-1524
US

IV. Provider business mailing address

9663 BIGGS RD
MIDDLE RIVER MD
21220-3789
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-7000
  • Fax:
Mailing address:
  • Phone: 443-570-0807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR171575
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR171575
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: