Healthcare Provider Details

I. General information

NPI: 1225097264
Provider Name (Legal Business Name): TAMARA T PETRIDES PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 EDGEWOOD ST
BALTIMORE MD
21216-2537
US

IV. Provider business mailing address

1905 REUTER RD
TIMONIUM MD
21093-4326
US

V. Phone/Fax

Practice location:
  • Phone: 410-396-0737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR099609
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: