Provider Demographics
NPI:1093000432
Name:WATCHEMSPROUT PEDIATRICS LLC
Entity Type:Organization
Organization Name:WATCHEMSPROUT PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:REUS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-433-0801
Mailing Address - Street 1:1190 W NORTHERN PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1431
Mailing Address - Country:US
Mailing Address - Phone:410-433-0801
Mailing Address - Fax:
Practice Address - Street 1:1190 W NORTHERN PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-1431
Practice Address - Country:US
Practice Address - Phone:410-433-0801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR146510363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty