Healthcare Provider Details

I. General information

NPI: 1275503633
Provider Name (Legal Business Name): KATHLEEN MCCLANAHAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24035 THREE NOTCH RD
HOLLYWOOD MD
20636-4871
US

IV. Provider business mailing address

24035 THREE NOTCH RD
HOLLYWOOD MD
20636-4871
US

V. Phone/Fax

Practice location:
  • Phone: 301-373-7900
  • Fax: 301-373-6900
Mailing address:
  • Phone: 301-373-7900
  • Fax: 301-373-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN63775
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR128846
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: