Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | R181291 | MD |
NPI | 1013314368 |
---|---|
Provider Name | Jessica De Grasse |
First Address | Berwyn Heights, MD 20740-2354 |
Second Address | College Park, MD 20740 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2014 |
Last Update Date | 29/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R181291 | CRNP PEDIATRIC LISENCE (01) | MD |