1235470147 NPI number — MRS. THERESA RUGALLA BOOKER CRNP

Table of content: MRS. THERESA RUGALLA BOOKER CRNP (NPI 1235470147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235470147 NPI number — MRS. THERESA RUGALLA BOOKER CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOOKER
Provider First Name:
THERESA
Provider Middle Name:
RUGALLA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUGALLA
Provider Other First Name:
THERESA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235470147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8518 79TH DIVISION BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MEADE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20755-1507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-512-8765
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4940 EASTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-550-9227
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  SP012500 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: R184354 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)