Healthcare Provider Details

I. General information

NPI: 1629731286
Provider Name (Legal Business Name): MAXINE LUGAY CRUZ-AM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S EXETER ST
BALTIMORE MD
21202-4316
US

IV. Provider business mailing address

510 DOGWOOD RD
LINTHICUM HEIGHTS MD
21090-2326
US

V. Phone/Fax

Practice location:
  • Phone: 410-962-6520
  • Fax:
Mailing address:
  • Phone: 443-867-7389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR223063
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: