Healthcare Provider Details

I. General information

NPI: 1063012664
Provider Name (Legal Business Name): SHAWNA MARIE HUTTON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2020
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1590
US

IV. Provider business mailing address

812 ORIOLE AVE
GLEN BURNIE MD
21060-8428
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-3100
  • Fax:
Mailing address:
  • Phone: 443-605-2263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR201776
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR201776
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: