MEDICARE: MRS. MARLENA RACHEL WAUGH CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	R176974	MD
2	363LG0600X	Gerontology Nurse Practitioner	R176974	MD

General Provider Information

NPI Number	:	1265728950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARLENA RACHEL WAUGH CRNP

Provider Business Mailing Address
First Line	:	3425 FOSTER AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-4106
Country	:	US
Telephone Number	:	443-708-4324
Fax Number	:

Provider Business Practice Location Address
First Line	:	4502 N CHARLES ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21210-2607
Country	:	US
Telephone Number	:	410-617-5055
Fax Number	:	410-617-2173

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2011
Last Update Date	:	06/22/2011

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