Healthcare Provider Details

I. General information

NPI: 1225813587
Provider Name (Legal Business Name): JACQUELYN ENGWALL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 UPPER CHESAPEAKE DR STE 518
BEL AIR MD
21014-4332
US

IV. Provider business mailing address

951 FELL ST APT 428
BALTIMORE MD
21231-3592
US

V. Phone/Fax

Practice location:
  • Phone: 443-643-4530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberR210283
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: