Healthcare Provider Details

I. General information

NPI: 1043602949
Provider Name (Legal Business Name): AMONDA BENTLEY WROE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 CENTRAL AVE
GLYNDON MD
21071-4216
US

IV. Provider business mailing address

PO BOX 28 317 CENTRAL AVE
GLYNDON MD
21071
US

V. Phone/Fax

Practice location:
  • Phone: 443-797-9241
  • Fax:
Mailing address:
  • Phone: 443-797-9241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR119539
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR119539
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR119539
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: