Healthcare Provider Details

I. General information

NPI: 1942605936
Provider Name (Legal Business Name): MARIA ROSARIO AGUSTIN DE LA CRUZ MSN, CRNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15485 PRINCE FREDERICK RD # 102
HUGHESVILLE MD
20637-9998
US

IV. Provider business mailing address

6279 BAYWOOD CT
HUGHESVILLE MD
20637-2575
US

V. Phone/Fax

Practice location:
  • Phone: 301-814-8228
  • Fax:
Mailing address:
  • Phone: 301-814-8228
  • Fax: 240-254-2187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR163177
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: