Provider Demographics
NPI:1326769464
Name:ELLIS, MINADIA ISAMAR (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MINADIA
Middle Name:ISAMAR
Last Name:ELLIS
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 1:7375 EXECUTIVE PL STE 400
Mailing Address - Street 2:#1023
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-6232
Mailing Address - Country:US
Mailing Address - Phone:301-323-8335
Mailing Address - Fax:833-740-4283
Practice Address - Street 1:7375 EXECUTIVE PL STE 400
Practice Address - Street 2:#1023
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-6232
Practice Address - Country:US
Practice Address - Phone:301-323-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC004629363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health