Provider Demographics
NPI:1508050469
Name:FAVAZZA, JENNIFER L (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:FAVAZZA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 LITTLE PATUXENT PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2655
Mailing Address - Country:US
Mailing Address - Phone:508-561-9344
Mailing Address - Fax:
Practice Address - Street 1:10175 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2655
Practice Address - Country:US
Practice Address - Phone:508-561-9344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA266644363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health