Provider Demographics
NPI:1861730863
Name:MIRA, JUSTYNA BRYS (CRNP-A)
Entity type:Individual
Prefix:
First Name:JUSTYNA
Middle Name:BRYS
Last Name:MIRA
Suffix:
Gender:F
Credentials:CRNP-A
Other - Prefix:
Other - First Name:JUSTYNA
Other - Middle Name:
Other - Last Name:BRYS MIRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-1002
Mailing Address - Country:US
Mailing Address - Phone:410-383-7443
Mailing Address - Fax:410-486-0399
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
Practice Address - Country:US
Practice Address - Phone:410-383-7443
Practice Address - Fax:410-486-0399
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR167354363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health