Healthcare Provider Details

I. General information

NPI: 1124982798
Provider Name (Legal Business Name): MODESTA VESONDER CRNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 E FURNACE BRANCH RD
GLEN BURNIE MD
21060-7059
US

IV. Provider business mailing address

7301 E FURNACE BRANCH RD
GLEN BURNIE MD
21060-7059
US

V. Phone/Fax

Practice location:
  • Phone: 443-548-1708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MODESTA VESONDER
Title or Position: CEO
Credential: CRNP
Phone: 301-875-1670