Provider Demographics
NPI:1285093047
Name:PANTOJA, JENNIFER LACEY (NP)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LACEY
Last Name:PANTOJA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LACEY
Other - Last Name:HUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:20805 FAIRWAY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20882-1841
Mailing Address - Country:US
Mailing Address - Phone:434-610-9811
Mailing Address - Fax:
Practice Address - Street 1:61 THOMAS JOHNSON DR STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4301
Practice Address - Country:US
Practice Address - Phone:240-215-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily