Healthcare Provider Details

I. General information

NPI: 1235652306
Provider Name (Legal Business Name): KATHRYN COLLETTE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN HUBER CRNP

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 01/25/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12502 WILLOWBROOK RD STE 660
CUMBERLAND MD
21502-6579
US

IV. Provider business mailing address

12502 WILLOWBROOK RD STE 660
CUMBERLAND MD
21502-6579
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-8760
  • Fax: 240-964-8769
Mailing address:
  • Phone: 240-964-8760
  • Fax: 240-964-8769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR220774
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR220774
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: