Provider Demographics
NPI:1326513169
Name:ELLERBE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ELLERBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 NEWBURY STREET
Mailing Address - Street 2:SUITE A OFFICE E
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209
Mailing Address - Country:US
Mailing Address - Phone:443-844-9448
Mailing Address - Fax:
Practice Address - Street 1:5550 NEWBURY STREET
Practice Address - Street 2:SUITE A OFFICE E
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209
Practice Address - Country:US
Practice Address - Phone:443-844-9448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR00652225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty