Provider Demographics
NPI:1114562246
Name:MCCLINNAHAN, EBONIQUE KATRESS (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:EBONIQUE
Middle Name:KATRESS
Last Name:MCCLINNAHAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 BELAIR GATE LN
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1943
Mailing Address - Country:US
Mailing Address - Phone:910-797-1491
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-4701
Practice Address - Country:US
Practice Address - Phone:301-295-0902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC002863363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health