Provider Demographics
NPI:1013253558
Name:STALEY, ELIZA
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:STALEY
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 1:9701 APOLLO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4785
Mailing Address - Country:US
Mailing Address - Phone:301-691-4987
Mailing Address - Fax:
Practice Address - Street 1:4520 E WEST HWY STE 775
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-0066
Practice Address - Country:US
Practice Address - Phone:667-668-2566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2023-12-20
Deactivation Date:2023-05-23
Deactivation Code:
Reactivation Date:2023-07-31
Provider Licenses
StateLicense IDTaxonomies
MDR250258363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health