Healthcare Provider Details

I. General information

NPI: 1265913982
Provider Name (Legal Business Name): GINA GRINSTEAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N BROADWAY STE 305G
BALTIMORE MD
21205-2004
US

IV. Provider business mailing address

550 N BROADWAY STE 305G
BALTIMORE MD
21205-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-1481
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR200835
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: