Provider Demographics
NPI:1376609248
Name:TIETJENS-GRILLO, LENORE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LENORE
Middle Name:MARIE
Last Name:TIETJENS-GRILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MISTY LN
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-2314
Mailing Address - Country:US
Mailing Address - Phone:443-553-0631
Mailing Address - Fax:
Practice Address - Street 1:9001 EDMONSTON RD STE 40
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-1004
Practice Address - Country:US
Practice Address - Phone:240-790-3325
Practice Address - Fax:301-345-1865
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0004254207VG0400X
MDD0046167207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD162081900Medicaid
MDG07314Medicare UPIN
MD162081900Medicaid