Provider Demographics
NPI:1164429973
Name:MASON, PHYLLIS J (CRNP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:J
Last Name:MASON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CHAMPIONSHIP CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5409
Mailing Address - Country:US
Mailing Address - Phone:410-902-7716
Mailing Address - Fax:
Practice Address - Street 1:911 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-1119
Practice Address - Country:US
Practice Address - Phone:410-614-6062
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MDR061925363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health