Healthcare Provider Details

I. General information

NPI: 1962118695
Provider Name (Legal Business Name): KATHRYN JANICE HEACOCK DNP, APRN-CNS, CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1590
US

IV. Provider business mailing address

1035 NABBS CREEK RD
GLEN BURNIE MD
21060-8435
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-4622
  • Fax:
Mailing address:
  • Phone: 919-593-4201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR226946
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License NumberCS00199
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: