Provider Demographics
NPI:1962740407
Name:ELLEN, REBECCA (CRNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ELLEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6999 REISTERSTOWN RD STE 4
Mailing Address - Street 2:ATTENTION REBECCA ELLEN
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-1492
Mailing Address - Country:US
Mailing Address - Phone:305-720-4743
Mailing Address - Fax:
Practice Address - Street 1:6999 REISTERSTOWN RD STE 4
Practice Address - Street 2:ATTENTION REBECCA ELLEN
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-1492
Practice Address - Country:US
Practice Address - Phone:305-720-4743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR222482363LP0808X
FLRN9228895363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily