Healthcare Provider Details

I. General information

NPI: 1619951464
Provider Name (Legal Business Name): JENNIFER LYNN WILSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER WILSON KELLER CRNP

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST CMCS 2 - NICU
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

616 EMERSON PL
SEVERNA PARK MD
21146-3410
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5255
  • Fax: 410-614-8834
Mailing address:
  • Phone: 410-544-4349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberR115360
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberR115360
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: