Healthcare Provider Details

I. General information

NPI: 1053879429
Provider Name (Legal Business Name): NOVA LA MARR PREVAL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2908 CABIN CREEK DR
BURTONSVILLE MD
20866-1839
US

IV. Provider business mailing address

2908 CABIN CREEK DR
BURTONSVILLE MD
20866-1839
US

V. Phone/Fax

Practice location:
  • Phone: 301-257-0563
  • Fax: 414-800-1839
Mailing address:
  • Phone: 301-257-0563
  • Fax: 414-800-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR213039
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR213039
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: