Healthcare Provider Details

I. General information

NPI: 1811997950
Provider Name (Legal Business Name): KATEY LYNN CRESSY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9815 MAIN STREET SUITE 208
DAMASCUS MD
20872-2002
US

IV. Provider business mailing address

9815 MAIN STREET SUITE 208
DAMASCUS MD
20872-2002
US

V. Phone/Fax

Practice location:
  • Phone: 301-253-4004
  • Fax: 301-253-3391
Mailing address:
  • Phone: 301-253-4004
  • Fax: 301-253-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002356
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: