Provider Demographics
NPI:1962910794
Name:GILLISPIE, LAANITA
Entity type:Individual
Prefix:
First Name:LAANITA
Middle Name:
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 THOMAS JOHNSON DR STE 215
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4527
Mailing Address - Country:US
Mailing Address - Phone:301-668-9988
Mailing Address - Fax:240-782-1013
Practice Address - Street 1:5 GARRETT AVE
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5960
Practice Address - Country:US
Practice Address - Phone:301-609-4285
Practice Address - Fax:301-934-6958
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN149605163W00000X
GA180952163W00000X
MDAC002237367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse