Provider Demographics
NPI:1881349199
Name:MASSENGALE, ANITA L (RN, BA, JD)
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:L
Last Name:MASSENGALE
Suffix:
Gender:F
Credentials:RN, BA, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 IRONBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-9486
Mailing Address - Country:US
Mailing Address - Phone:301-717-5473
Mailing Address - Fax:
Practice Address - Street 1:6920 IRONBRIDGE LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-9486
Practice Address - Country:US
Practice Address - Phone:301-717-5473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR104904163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse