Healthcare Provider Details

I. General information

NPI: 1699259580
Provider Name (Legal Business Name): KEITH DIBENEDETTO CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11121 YORK RD
HUNT VALLEY MD
21030-2006
US

IV. Provider business mailing address

11121 YORK RD
HUNT VALLEY MD
21030-2006
US

V. Phone/Fax

Practice location:
  • Phone: 410-628-2026
  • Fax: 410-667-6834
Mailing address:
  • Phone: 410-628-2026
  • Fax: 410-667-6834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR210044
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR210044
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: