Healthcare Provider Details

I. General information

NPI: 1962495382
Provider Name (Legal Business Name): BETSY BLANK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 CARRY PL
CROFTON MD
21114-2324
US

IV. Provider business mailing address

PO BOX 465
LOTHIAN MD
20711-0465
US

V. Phone/Fax

Practice location:
  • Phone: 301-751-3888
  • Fax: 301-262-7383
Mailing address:
  • Phone: 301-751-3888
  • Fax: 301-262-7383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR097929
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: