Provider Demographics
NPI:1790069490
Name:GILLIS, STEPHANIE RAE (MS, NP-C, CRNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RAE
Last Name:GILLIS
Suffix:
Gender:F
Credentials:MS, NP-C, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3159 PINE ORCHARD LN APT 302
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-4223
Mailing Address - Country:US
Mailing Address - Phone:443-420-8391
Mailing Address - Fax:
Practice Address - Street 1:3300 CENTENNIAL LN
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3600
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily