Healthcare Provider Details

I. General information

NPI: 1508133927
Provider Name (Legal Business Name): PHYLLIS ELANA BROWN C.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RESERVOIR CIRCLE STE. #201
BALTIMORE MD
21208
US

IV. Provider business mailing address

1 RESERVOIR CIRCLE STE. #201
BALTIMORE MD
21208
US

V. Phone/Fax

Practice location:
  • Phone: 410-602-3322
  • Fax: 410-602-8363
Mailing address:
  • Phone: 410-602-3322
  • Fax: 410-602-8363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberANCC-0021755
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR068465
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: