Provider Demographics
NPI:1639883507
Name:ELDER, STACEY AURELIA (LE, CPE)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:AURELIA
Last Name:ELDER
Suffix:
Gender:F
Credentials:LE, CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 YORK RD STE 209
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-2024
Mailing Address - Country:US
Mailing Address - Phone:410-235-2211
Mailing Address - Fax:
Practice Address - Street 1:6600 YORK RD STE 209
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-2024
Practice Address - Country:US
Practice Address - Phone:410-235-2211
Practice Address - Fax:443-991-4320
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDEO1288174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty