Healthcare Provider Details

I. General information

NPI: 1316724842
Provider Name (Legal Business Name): ANTIETAM FAMILY HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 E PATRICK ST
FREDERICK MD
21701-5777
US

IV. Provider business mailing address

1219 MOUNT AETNA RD STE 201
HAGERSTOWN MD
21742-6550
US

V. Phone/Fax

Practice location:
  • Phone: 240-203-8864
  • Fax:
Mailing address:
  • Phone: 240-203-8864
  • Fax: 240-866-8173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARK ANTHONY RONCONE
Title or Position: OWNER/PROVIDER
Credential:
Phone: 240-203-8864