Healthcare Provider Details

I. General information

NPI: 1861768699
Provider Name (Legal Business Name): MARY CLARE GODINEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 FLEET ST STE 200
BALTIMORE MD
21224-4200
US

IV. Provider business mailing address

3501 SINCLAIR LN
BALTIMORE MD
21213-2029
US

V. Phone/Fax

Practice location:
  • Phone: 410-558-4900
  • Fax: 410-522-2070
Mailing address:
  • Phone: 410-732-8800
  • Fax: 410-534-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR200346
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0001227118
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: