Provider Demographics
NPI:1083663058
Name:ECKENRODE, DELORETTA THERESA (NP)
Entity Type:Individual
Prefix:
First Name:DELORETTA
Middle Name:THERESA
Last Name:ECKENRODE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DELORETTA
Other - Middle Name:THERESA
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
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
Mailing Address - Country:US
Mailing Address - Phone:410-329-1071
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:67 SAND PIT RD STE 308
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-743-7264
Practice Address - Fax:203-792-3920
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332927363L00000X
CT3709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001644Medicaid