Provider Demographics
NPI:1588859391
Name:SPONN, CAROLYN PATRICIA (CRNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:PATRICIA
Last Name:SPONN
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 1:4390 MONTGOMERY RD
Mailing Address - Street 2:TARGET CLINIC
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6068
Mailing Address - Country:US
Mailing Address - Phone:410-203-1700
Mailing Address - Fax:410-203-1026
Practice Address - Street 1:4390 MONTGOMERY RD
Practice Address - Street 2:TARGET CLINIC
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6068
Practice Address - Country:US
Practice Address - Phone:410-203-1700
Practice Address - Fax:410-203-1026
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily