Provider Demographics
NPI:1598151144
Name:ENSSLIN, COURTNEY JADE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JADE
Last Name:ENSSLIN
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 1:4 SHAKER DR
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12211-1825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 WATKINS MILL RD
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3301
Practice Address - Country:US
Practice Address - Phone:240-632-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD89328207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program