Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | R224996 | MD |
NPI | 1003381997 |
---|---|
Provider Name | Martha Reilley |
First Address | Stafford, VA 22554-1532 |
Second Address | Baltimore, MD 21224-5251 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/10/2018 |
Last Update Date | 08/10/2018 |