Healthcare Provider Details

I. General information

NPI: 1760265391
Provider Name (Legal Business Name): IMMANUELLIN DELFIN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 HOSPITAL DR STE 204
ROSEDALE MD
21237-4377
US

IV. Provider business mailing address

6 MAYA WAY
ROSEDALE MD
21237-4242
US

V. Phone/Fax

Practice location:
  • Phone: 443-559-5063
  • Fax:
Mailing address:
  • Phone: 443-938-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR188794
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR188794
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: