Healthcare Provider Details

I. General information

NPI: 1609848050
Provider Name (Legal Business Name): MARY SMITH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 FOREST GLEN RD
SILVER SPRING MD
20910-1460
US

IV. Provider business mailing address

PO BOX 2130
GERMANTOWN MD
20875-2130
US

V. Phone/Fax

Practice location:
  • Phone: 240-364-2510
  • Fax:
Mailing address:
  • Phone: 240-364-2510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberR063119
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: