Provider Demographics
NPI:1154007409
Name:OLDS, MARY ALICE (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:OLDS
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 1:4775 ILKLEY MOOR LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6531
Mailing Address - Country:US
Mailing Address - Phone:443-904-2099
Mailing Address - Fax:
Practice Address - Street 1:4775 ILKLEY MOOR LN
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6531
Practice Address - Country:US
Practice Address - Phone:443-904-2099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR199404207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine