MEDICARE: REZVANEH GOODARZI 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	363LF0000X	Family Nurse Practitioner	F09201007	MD

General Provider Information

NPI Number	:	1316544315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REZVANEH GOODARZI CRNP

Provider Business Mailing Address
First Line	:	5450 KNOLL NORTH DR STE 260
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2394
Country	:	US
Telephone Number	:	410-964-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	5450 KNOLL NORTH DR STE 250
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2368
Country	:	US
Telephone Number	:	410-964-6115
Fax Number	:	410-964-5315

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

Provider Enumeration Date	:	10/03/2020
Last Update Date	:	03/21/2023

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