1053864702 NPI number — MARIA JENNIFFER R WESOLOWSKI NP

Table of content: MARIA JENNIFFER R WESOLOWSKI NP (NPI 1053864702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053864702 NPI number — MARIA JENNIFFER R WESOLOWSKI NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WESOLOWSKI
Provider First Name:
MARIA JENNIFFER
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARAGAN
Provider Other First Name:
MARIA JENNIFFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053864702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37174
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-3174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-423-5699
Provider Business Mailing Address Fax Number:
571-423-5698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 GALLOWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22042-3307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-415-4116
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2016

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: 363L00000X , with the licence number:  0024173785 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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