Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | R217581 | MD |
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | RN2274139 | MA |
NPI | 1023449642 |
---|---|
Provider Name | Ms. Mary Gordon Walter |
First Address | Prince Frederick, MD 20678-3917 |
Second Address | Prince Frederick, MD 20678 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/12/2013 |
Last Update Date | 29/09/2015 |