Healthcare Provider Details

I. General information

NPI: 1568013316
Provider Name (Legal Business Name): CATHERINE ELAINE GANNON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 WOODBROOKE DR
SALISBURY MD
21804-8501
US

IV. Provider business mailing address

1630 WOODBROOKE DR
SALISBURY MD
21804-8501
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-6330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR200736
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0001328
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: