Provider Demographics
NPI:1518129642
Name:BURNETT, BRYN MOIRA (RN-CRNP)
Entity Type:Individual
Prefix:MRS
First Name:BRYN
Middle Name:MOIRA
Last Name:BURNETT
Suffix:
Gender:F
Credentials:RN-CRNP
Other - Prefix:
Other - First Name:BRYN
Other - Middle Name:
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA I, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-1002
Mailing Address - Country:US
Mailing Address - Phone:443-643-3000
Mailing Address - Fax:443-643-3001
Practice Address - Street 1:510 UPPER CHESAPEAKE DR
Practice Address - Street 2:SUITE 415
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4328
Practice Address - Country:US
Practice Address - Phone:443-643-3000
Practice Address - Fax:443-643-3001
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR116372363LA2200X
PAVP005253V363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028308560001Medicaid
MDD38532OtherSTATE LICENSE