Healthcare Provider Details

I. General information

NPI: 1932979978
Provider Name (Legal Business Name): HEATHER PRIDEMORE DELAUTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 04/12/2025
Certification Date: 04/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 THOMAS JOHNSON DR STE E
FREDERICK MD
21702-4399
US

IV. Provider business mailing address

63 THOMAS JOHNSON DR STE E
FREDERICK MD
21702-4399
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-7600
  • Fax:
Mailing address:
  • Phone: 301-694-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR211268
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: