Provider Demographics
NPI:1821181959
Name:KING, MARIETTA (CRNP-F)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:CRNP-F
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7939 HONEYGO BLVD
Mailing Address - Street 2:SUITE 219
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4931
Mailing Address - Country:US
Mailing Address - Phone:410-931-0404
Mailing Address - Fax:410-931-0405
Practice Address - Street 1:7939 HONEYGO BLVD
Practice Address - Street 2:SUITE 219
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4931
Practice Address - Country:US
Practice Address - Phone:410-931-0404
Practice Address - Fax:410-931-0405
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR150042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD145105560Medicaid
MD189LL758Medicare ID - Type Unspecified
MDP63789Medicare UPIN