Healthcare Provider Details

I. General information

NPI: 1124652284
Provider Name (Legal Business Name): QUIEBONNIE M MCDONALD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 WILKENS AVE
BALTIMORE MD
21229-4610
US

IV. Provider business mailing address

3330 WILKENS AVE
BALTIMORE MD
21229-4610
US

V. Phone/Fax

Practice location:
  • Phone: 410-525-1544
  • Fax: 410-525-3146
Mailing address:
  • Phone: 410-525-1544
  • Fax: 410-525-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR196487
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: