Healthcare Provider Details

I. General information

NPI: 1508050469
Provider Name (Legal Business Name): JENNIFER L FAVAZZA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10175 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-2655
US

IV. Provider business mailing address

10175 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-2655
US

V. Phone/Fax

Practice location:
  • Phone: 508-561-9344
  • Fax:
Mailing address:
  • Phone: 508-561-9344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number266644
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number266644
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: