Healthcare Provider Details

I. General information

NPI: 1750384038
Provider Name (Legal Business Name): TONI T DURHAM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD
BALTIMORE MD
21239-2905
US

IV. Provider business mailing address

1836 GLEN RIDGE RD
BALTIMORE MD
21234-5214
US

V. Phone/Fax

Practice location:
  • Phone: 410-532-4232
  • Fax: 410-532-4623
Mailing address:
  • Phone: 410-532-4232
  • Fax: 410-532-4623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR062761
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: