Healthcare Provider Details

I. General information

NPI: 1679329205
Provider Name (Legal Business Name): ANGELA GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 ROCK SPRING RD STE C
FOREST HILL MD
21050-2818
US

IV. Provider business mailing address

3020 LOCHARY RD
BEL AIR MD
21015-1026
US

V. Phone/Fax

Practice location:
  • Phone: 410-838-6358
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR241923
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR241923
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: