Provider Demographics
NPI:1972664241
Name:ELIJAH, SARA LEE (LAC)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:LEE
Last Name:ELIJAH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 EGRET WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-1913
Mailing Address - Country:US
Mailing Address - Phone:410-967-1773
Mailing Address - Fax:
Practice Address - Street 1:176 THOMAS JOHNSON DR STE 204
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4538
Practice Address - Country:US
Practice Address - Phone:410-967-1773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU 01125171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD039242OtherJOHNS HOPKINS EHP INSURAN
MDH998OtherCAREFIRST BLUECROSS
MDBN54SLOtherCAREFIRST BLUECROSS