Healthcare Provider Details

I. General information

NPI: 1720553506
Provider Name (Legal Business Name): KAREN LISA WIRTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3581 OLD WASHINGTON RD
WALDORF MD
20602-3270
US

IV. Provider business mailing address

3581 OLD WASHINGTON RD
WALDORF MD
20602-3270
US

V. Phone/Fax

Practice location:
  • Phone: 301-638-4400
  • Fax: 301-638-2200
Mailing address:
  • Phone: 301-638-4400
  • Fax: 301-638-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR194273
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: