Provider Demographics
NPI:1932282134
Name:RACKSON, MARY A (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:RACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:410-500-4266
Practice Address - Street 1:10155 YORK RD
Practice Address - Street 2:STE 200
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-3352
Practice Address - Country:US
Practice Address - Phone:410-628-2026
Practice Address - Fax:410-628-6507
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDRO77166207Q00000X
MDR017766363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD246581700Medicaid
MDP031Medicare PIN