Healthcare Provider Details

I. General information

NPI: 1558891697
Provider Name (Legal Business Name): MARTHA GRACE WACHENHEIM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARTHA GRACE ZASADNY

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0942
  • Fax: 410-550-0443
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number253087
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9391766
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAC003760
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: