Healthcare Provider Details

I. General information

NPI: 1093000432
Provider Name (Legal Business Name): WATCHEMSPROUT PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 W NORTHERN PKWY SUITE 101
BALTIMORE MD
21210-1431
US

IV. Provider business mailing address

1190 W NORTHERN PKWY SUITE 101
BALTIMORE MD
21210-1431
US

V. Phone/Fax

Practice location:
  • Phone: 410-433-0801
  • Fax:
Mailing address:
  • Phone: 410-433-0801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR146510
License Number StateMD

VIII. Authorized Official

Name: MRS. MARY T REUS
Title or Position: NURSE PRACTITIONER
Credential: CRNP
Phone: 410-433-0801