Healthcare Provider Details

I. General information

NPI: 1114676822
Provider Name (Legal Business Name): ALEXANDRA MOUNTFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 OLD WASHINGTON RD STE 101
WALDORF MD
20602-3205
US

IV. Provider business mailing address

3500 OLD WASHINGTON RD STE 101
WALDORF MD
20602-3205
US

V. Phone/Fax

Practice location:
  • Phone: 301-885-5020
  • Fax: 240-419-5217
Mailing address:
  • Phone: 301-885-5020
  • Fax: 240-419-5217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAC004175
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAC004176
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: