Provider Demographics
NPI:1457051831
Name:ELLIE OF MARYLAND LLC
Entity Type:Organization
Organization Name:ELLIE OF MARYLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRANCHISE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STAMPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-336-9745
Mailing Address - Street 1:900 BESTGATE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7922
Mailing Address - Country:US
Mailing Address - Phone:410-267-3706
Mailing Address - Fax:
Practice Address - Street 1:900 BESTGATE RD STE 210
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7922
Practice Address - Country:US
Practice Address - Phone:410-267-3706
Practice Address - Fax:443-782-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty