Provider Demographics
NPI:1275535452
Name:WADDELL-VANDEGEIJN, BETH ANN (CRNP)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:ANN
Last Name:WADDELL-VANDEGEIJN
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 1:3100 WYMAN PARK DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2803
Mailing Address - Country:US
Mailing Address - Phone:410-338-3500
Mailing Address - Fax:
Practice Address - Street 1:2112 DUNDALK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-3714
Practice Address - Country:US
Practice Address - Phone:410-288-4800
Practice Address - Fax:410-288-1424
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR112485363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP30135Medicare UPIN