Healthcare Provider Details

I. General information

NPI: 1699776831
Provider Name (Legal Business Name): PHYLLIS M WELLS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11085 LITTLE PATUXENT PKWY STE 103
COLUMBIA MD
21044-2983
US

IV. Provider business mailing address

11085 LITTLE PATUXENT PKWY STE 103
COLUMBIA MD
21044-2983
US

V. Phone/Fax

Practice location:
  • Phone: 410-997-0580
  • Fax: 410-740-8587
Mailing address:
  • Phone: 410-997-0580
  • Fax: 410-740-8587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberQ29866
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: