Healthcare Provider Details

I. General information

NPI: 1497353973
Provider Name (Legal Business Name): BETHANY A CORRELLI FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6635 BELAIR RD
BALTIMORE MD
21206-1845
US

IV. Provider business mailing address

6635 BELAIR RD
BALTIMORE MD
21206-1845
US

V. Phone/Fax

Practice location:
  • Phone: 410-254-9755
  • Fax:
Mailing address:
  • Phone: 410-254-9755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC003660
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number28225364A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: