Provider Demographics
NPI:1699149492
Name:DEGRAFENREID, REGINALD EUGENE JR (NP, PMH-NP)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:EUGENE
Last Name:DEGRAFENREID
Suffix:JR
Gender:M
Credentials:NP, PMH-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1408
Mailing Address - Country:US
Mailing Address - Phone:410-733-2544
Mailing Address - Fax:
Practice Address - Street 1:1866 REISTERSTOWN RD
Practice Address - Street 2:F
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-1335
Practice Address - Country:US
Practice Address - Phone:410-484-5642
Practice Address - Fax:410-484-5541
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR193260363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily