Provider Demographics
NPI:1336859610
Name:MASSALLA, ERNEST
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:
Last Name:MASSALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 POSTGATE TER APT 102
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-6009
Mailing Address - Country:US
Mailing Address - Phone:240-277-6216
Mailing Address - Fax:
Practice Address - Street 1:4005 POSTGATE TER APT 102
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-6009
Practice Address - Country:US
Practice Address - Phone:240-277-6216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR224711363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health