Provider Demographics
NPI:1780740464
Name:ZOLTAK, BRENDA M (CRNP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:M
Last Name:ZOLTAK
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 1:7310 RITCHIE HWY
Mailing Address - Street 2:SUITE 516
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3065
Mailing Address - Country:US
Mailing Address - Phone:410-761-7305
Mailing Address - Fax:410-761-7387
Practice Address - Street 1:7310 RITCHIE HWY
Practice Address - Street 2:SUITE 516
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3065
Practice Address - Country:US
Practice Address - Phone:410-761-7305
Practice Address - Fax:410-761-7387
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR101670363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP96948Medicare UPIN
MD012467K92Medicare ID - Type Unspecified