Healthcare Provider Details

I. General information

NPI: 1487609590
Provider Name (Legal Business Name): KATHRYN ANN BLACKFORD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 MAIDEN CHOICE LN
CATONSVILLE MD
21228-3632
US

IV. Provider business mailing address

813 MAIDEN CHOICE LN
BALTIMORE MD
21228-3679
US

V. Phone/Fax

Practice location:
  • Phone: 410-247-5602
  • Fax: 410-242-1756
Mailing address:
  • Phone: 410-402-2258
  • Fax: 410-204-7279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR047324
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: