Basic Information
| Provider Information | |||||||||
| NPI: | 1992045363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NANCE | ||||||||
| FirstName: | GENA | ||||||||
| MiddleName: | DENICE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 314 FRANKLIN AVE STE 304 | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106291450 | ||||||||
| FaxNumber: | 4106291460 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 FRANKLIN AVE STE 304 | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106291450 | ||||||||
| FaxNumber: | 4106291460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2013 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AC003077 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R173550 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 119591300 | 05 | MD | MEDICAID | 1992045363 | 05 | MD | MEDICAID |