=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518057371
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN STAPLES CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 S HAYS ST
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-3644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-638-8484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 97 WINCHESTER CT
-----------------------------------------------------
City | PORT DEPOSIT
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21904-1558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-378-4306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number | R039586
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------