Healthcare Provider Details

I. General information

NPI: 1639525108
Provider Name (Legal Business Name): KIM DRUCIS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N BROADWAY ST ROOM 1341
BALTIMORE MD
21287-0019
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-502-0712
  • Fax: 410-614-6466
Mailing address:
  • Phone: 410-933-1340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR140888
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: