Healthcare Provider Details

I. General information

NPI: 1629451190
Provider Name (Legal Business Name): REBECCA ALIZA THEISE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 LIBERTY RD STE 205
ELDERSBURG MD
21784-6542
US

IV. Provider business mailing address

3911 N CHARLES ST
BALTIMORE MD
21218-1733
US

V. Phone/Fax

Practice location:
  • Phone: 203-481-7008
  • Fax:
Mailing address:
  • Phone: 917-613-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR226346
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: