Provider Demographics
NPI:1023449642
Name:WALTER, MARY GORDON (RN/NP, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:GORDON
Last Name:WALTER
Suffix:
Gender:F
Credentials:RN/NP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SOLOMONS ISLAND RD N
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:976 SOLOMANS ISLAND ROAD
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678
Practice Address - Country:US
Practice Address - Phone:410-535-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-07
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2274139163WE0003X, 363LP0808X
MDR217581363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency