Healthcare Provider Details

I. General information

NPI: 1831001429
Provider Name (Legal Business Name): KEITH JOSEPH DEWALD CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 OLD FORGE CT
SPARKS GLENCOE MD
21152-8850
US

IV. Provider business mailing address

6 OLD FORGE CT
SPARKS GLENCOE MD
21152-8850
US

V. Phone/Fax

Practice location:
  • Phone: 443-992-3577
  • Fax:
Mailing address:
  • Phone: 443-992-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR195611
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: