Healthcare Provider Details

I. General information

NPI: 1942556220
Provider Name (Legal Business Name): MARY TERESA GRACE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 MAIDEN CHOICE LN STE 350
CATONSVILLE MD
21228-3692
US

IV. Provider business mailing address

1119 VINEYARD HILL RD
CATONSVILLE MD
21228-5377
US

V. Phone/Fax

Practice location:
  • Phone: 410-242-9001
  • Fax:
Mailing address:
  • Phone: 410-218-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR066268
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: