Healthcare Provider Details

I. General information

NPI: 1760726269
Provider Name (Legal Business Name): CHARLENE MARIE GANTT CRNP PMH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARLENE MARIE ROZICH PMHNP

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5970 FREDERICK CROSSING LN STE 100
FREDERICK MD
21704-5176
US

IV. Provider business mailing address

515 MOUND BUILDER LOOP
HEDGESVILLE WV
25427-7833
US

V. Phone/Fax

Practice location:
  • Phone: 240-415-6373
  • Fax:
Mailing address:
  • Phone: 240-415-8893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024170482
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: