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General NPI Number Information
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NPI Number | 1528927647
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Entity Type | Individual
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Provider Name | MARY GRACE LEGASPI WILD MSN, RN, AGPCNP-BC
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Gender | Female
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Dates
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Enumeration Date | 01/16/2026
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Last Update Date | 01/16/2026
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Provider Practice Location Address
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Address Line | 12200 ANNAPOLIS RD STE 115
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City | GLENN DALE
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State | MD
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Zip | 20769-9182
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Country | US
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Telephone | 301-805-7084
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Fax |
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Provider Business Mailing Address
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Address Line | 4335 SLATER AVE
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City | NOTTINGHAM
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State | MD
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Zip | 21236-2725
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Country | US
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Telephone | 301-805-7084
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | R164664
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License Number State | MD
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