Healthcare Provider Details

I. General information

NPI: 1871199026
Provider Name (Legal Business Name): AYROWYN TANNER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-2757
  • Fax:
Mailing address:
  • Phone: 443-923-2757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10484809-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR235108
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: