Healthcare Provider Details

I. General information

NPI: 1760535397
Provider Name (Legal Business Name): BRONWYN ELIZABETH DAUGHERTY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 CHARLES ST
LA PLATA MD
20646-5930
US

IV. Provider business mailing address

21845 PLACENTIA FARM LN
LEONARDTOWN MD
20650-4118
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4000
  • Fax:
Mailing address:
  • Phone: 301-475-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR100470
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: