Healthcare Provider Details

I. General information

NPI: 1437867728
Provider Name (Legal Business Name): STACIAN NWAUKWA DNP, CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BRIAN DANIEL CT
REISTERSTOWN MD
21136-4635
US

IV. Provider business mailing address

12 BRIAN DANIEL CT
REISTERSTOWN MD
21136-4635
US

V. Phone/Fax

Practice location:
  • Phone: 410-413-0376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR178638
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR178638
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: