Healthcare Provider Details

I. General information

NPI: 1760042899
Provider Name (Legal Business Name): MARY J SHADE FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 N ROLLING RD STE 305
CATONSVILLE MD
21228-4142
US

IV. Provider business mailing address

PO BOX 147
HAVRE DE GRACE MD
21078-0147
US

V. Phone/Fax

Practice location:
  • Phone: 301-241-6070
  • Fax: 570-410-8110
Mailing address:
  • Phone: 301-241-6070
  • Fax: 570-410-8110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00933800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP036380
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00933800
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR238464
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR238464
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP035477
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: