Healthcare Provider Details

I. General information

NPI: 1285137497
Provider Name (Legal Business Name): REBECCA GUM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 40TH ST STE 173
BALTIMORE MD
21211-2147
US

IV. Provider business mailing address

711 W 40TH ST STE 173
BALTIMORE MD
21211-2147
US

V. Phone/Fax

Practice location:
  • Phone: 443-961-1221
  • Fax:
Mailing address:
  • Phone: 443-961-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC002258
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: