Provider Demographics
NPI:1659957785
Name:GUTTER, DALISA EBONI (WHNP)
Entity Type:Individual
Prefix:
First Name:DALISA
Middle Name:EBONI
Last Name:GUTTER
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ELKRIDGE LANDING RD FL 2
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2924
Mailing Address - Country:US
Mailing Address - Phone:443-462-5010
Mailing Address - Fax:
Practice Address - Street 1:101 E CHARLES ST STE 104
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-4901
Practice Address - Country:US
Practice Address - Phone:301-609-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR261585363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health