Provider Demographics
NPI:1508428103
Name:DEROSA, CONSTANCE MARIA
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:MARIA
Last Name:DEROSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37086
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3086
Mailing Address - Country:US
Mailing Address - Phone:240-439-8812
Mailing Address - Fax:
Practice Address - Street 1:1562 OPOSSUMTOWN PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4920
Practice Address - Country:US
Practice Address - Phone:402-566-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR119937363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health