Provider Demographics
NPI:1922438357
Name:MOSKOVITZ, MARYBETH GRANNIS (CNM, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:GRANNIS
Last Name:MOSKOVITZ
Suffix:
Gender:F
Credentials:CNM, PMHNP-BC
Other - Prefix:
Other - First Name:MARYBETH
Other - Middle Name:
Other - Last Name:GRANNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2600 SOLOMONS ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-1102
Mailing Address - Country:US
Mailing Address - Phone:443-433-5900
Mailing Address - Fax:
Practice Address - Street 1:2600 SOLOMONS ISLAND RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1102
Practice Address - Country:US
Practice Address - Phone:443-443-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-21
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR175707363LX0001X, 363LP0808X
DCRN1007233363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology