Provider Demographics
NPI:1871539064
Name:GONSALVES, MARYLYNN (NP)
Entity type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GIRARD ST
Mailing Address - Street 2:SUITE 212A
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-3466
Mailing Address - Country:US
Mailing Address - Phone:301-216-0880
Mailing Address - Fax:
Practice Address - Street 1:200 GIRARD ST STE 212
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-3490
Practice Address - Country:US
Practice Address - Phone:301-216-0880
Practice Address - Fax:301-216-2891
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13979363L00000X
MDR136202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner