Healthcare Provider Details

I. General information

NPI: 1063009694
Provider Name (Legal Business Name): AMANDA MITTELSTETTER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 FREDERICK RD
CATONSVILLE MD
21228-4516
US

IV. Provider business mailing address

910 FREDERICK RD
CATONSVILLE MD
21228-4516
US

V. Phone/Fax

Practice location:
  • Phone: 410-644-1880
  • Fax: 410-646-3623
Mailing address:
  • Phone: 410-644-1880
  • Fax: 410-646-3623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR218961
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR218961
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: