Basic Information
| Provider Information | |||||||||
| NPI: | 1306311717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAMEDOV | ||||||||
| FirstName: | NANETTE | ||||||||
| MiddleName: | GABRIELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP-FAMILY | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILKIS | ||||||||
| OtherFirstName: | NANETTE | ||||||||
| OtherMiddleName: | GABRIELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP-FAMILY | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7601 OSLER DR | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212047700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103371000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7601 OSLER DR | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212047700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103371000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2018 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | R184664 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
No ID Information.