Provider Demographics
NPI:1851494488
Name:VITUCCI, BRENDA L (CRNP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:VITUCCI
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 1:14303 LAKE ROYER DR
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:MD
Mailing Address - Zip Code:21719-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14303 LAKE ROYER DR
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:MD
Practice Address - Zip Code:21719-1602
Practice Address - Country:US
Practice Address - Phone:240-852-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR081680363LF0000X
PASP015218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103040951Medicaid
I281Medicare ID - Type Unspecified
PA103040951Medicaid