Provider Demographics
NPI:1588719678
Name:STEPHENS, ELISABETH SUZANNE (PA-C)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:SUZANNE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:SUZANNE
Other - Last Name:BELLAMY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9910 FRANKLIN SQUARE DR # 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-5412
Mailing Address - Fax:
Practice Address - Street 1:20500 SENECA MEADOWS PKWY STE 2400
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-7014
Practice Address - Country:US
Practice Address - Phone:240-912-2738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0003435OtherLICENSE