Healthcare Provider Details

I. General information

NPI: 1083539563
Provider Name (Legal Business Name): JENNIFER DIFATTA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 FAIRMOUNT AVE STE 330
TOWSON MD
21286-5466
US

IV. Provider business mailing address

515 FAIRMOUNT AVE STE 400
TOWSON MD
21286-8518
US

V. Phone/Fax

Practice location:
  • Phone: 410-494-1313
  • Fax: 410-584-2250
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR172197
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: