Provider Demographics
NPI:1396772257
Name:RUNNER, JACQUELINE RENE (FNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENE
Last Name:RUNNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:RENE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2209 DEFENSE HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2403
Mailing Address - Country:US
Mailing Address - Phone:443-332-4260
Mailing Address - Fax:
Practice Address - Street 1:2114 GENERALS HWY
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7488
Practice Address - Country:US
Practice Address - Phone:888-808-6483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR111672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010188733Medicaid
VA010188652Medicaid
VA010188695Medicaid
MD255202700Medicaid
VA010188768Medicaid
VA010188733Medicaid
VAQ52895Medicare UPIN