Healthcare Provider Details

I. General information

NPI: 1598160608
Provider Name (Legal Business Name): LAURA WEDERTZ CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 THOMAS JOHNSON DR
FREDERICK MD
21702-4679
US

IV. Provider business mailing address

2461 BRADDOCK RD
MOUNT AIRY MD
21771-8801
US

V. Phone/Fax

Practice location:
  • Phone: 240-215-6370
  • Fax:
Mailing address:
  • Phone: 434-340-5962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR185929
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: