Provider Demographics
NPI:1508185505
Name:REIDY, JAMIE LEE (MSN, PNP, WHNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:REIDY
Suffix:
Gender:F
Credentials:MSN, PNP, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 CENTENNIAL ST B
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5985
Mailing Address - Country:US
Mailing Address - Phone:301-934-9111
Mailing Address - Fax:
Practice Address - Street 1:103 CENTENNIAL ST
Practice Address - Street 2:SUITE B
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5984
Practice Address - Country:US
Practice Address - Phone:301-643-8127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR162903363LP0200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD033338700Medicaid