Healthcare Provider Details

I. General information

NPI: 1558749267
Provider Name (Legal Business Name): ZELBESA VAILIIDA DAKUE MACK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 HADDINGTON RD
TIMONIUM MD
21093-5719
US

IV. Provider business mailing address

28 HADDINGTON RD
TIMONIUM MD
21093-5719
US

V. Phone/Fax

Practice location:
  • Phone: 410-961-0844
  • Fax:
Mailing address:
  • Phone: 410-961-0844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR137492
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR137492
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR137492
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: