Provider Demographics
NPI:1497888226
Name:VAN DERMARK, ELIZABETH ANNE (CRNP-A, WH)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:VAN DERMARK
Suffix:
Gender:F
Credentials:CRNP-A, WH
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WHITTINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:21031-1002
Mailing Address - Country:US
Mailing Address - Phone:301-620-0012
Mailing Address - Fax:301-620-9687
Practice Address - Street 1:75 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE C
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4895
Practice Address - Country:US
Practice Address - Phone:301-620-0012
Practice Address - Fax:301-620-9687
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR086553363LW0102X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR086553OtherMD LICENSE