Provider Demographics
NPI:1043505324
Name:ELLERMAN, JUSTINE S (CRNP)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:S
Last Name:ELLERMAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 76
Mailing Address - Street 2:
Mailing Address - City:SAINT LEONARD
Mailing Address - State:MD
Mailing Address - Zip Code:20685-0076
Mailing Address - Country:US
Mailing Address - Phone:516-754-3268
Mailing Address - Fax:
Practice Address - Street 1:400 BALL RD
Practice Address - Street 2:
Practice Address - City:SAINT LEONARD
Practice Address - State:MD
Practice Address - Zip Code:20685-2116
Practice Address - Country:US
Practice Address - Phone:516-754-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR191521363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health