Healthcare Provider Details

I. General information

NPI: 1841208576
Provider Name (Legal Business Name): PALESTINE A SEWELL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USAMEDDAC 2480 LLEWELLYN AVE
FORT GEORGE G MEADE MD
20755
US

IV. Provider business mailing address

1434 PORTER ST
FORT DETRICK MD
21702-9254
US

V. Phone/Fax

Practice location:
  • Phone: 301-619-4633
  • Fax: 301-619-4635
Mailing address:
  • Phone: 301-619-7175
  • Fax: 301-619-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR088541
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberRO88541
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberRO88541
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: