Healthcare Provider Details

I. General information

NPI: 1033865134
Provider Name (Legal Business Name): CECILIA GUTWALD AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1590
US

IV. Provider business mailing address

11405 SMILOFF RD
WHITE MARSH MD
21162-1421
US

V. Phone/Fax

Practice location:
  • Phone: 443-345-7797
  • Fax:
Mailing address:
  • Phone: 443-345-7797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR212024
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberR212024
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR212024
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: