Healthcare Provider Details

I. General information

NPI: 1245862648
Provider Name (Legal Business Name): EMMANUEL A GBALA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E CHERRY HILL RD
REISTERSTOWN MD
21136-3023
US

IV. Provider business mailing address

117 E CHERRY HILL RD
REISTERSTOWN MD
21136-3023
US

V. Phone/Fax

Practice location:
  • Phone: 443-204-3919
  • Fax: 410-521-3671
Mailing address:
  • Phone: 443-204-3919
  • Fax: 410-521-3671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR189984
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: