Healthcare Provider Details

I. General information

NPI: 1518025824
Provider Name (Legal Business Name): ELLEN REILLEY FARRELL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4579 WILLOWS RD
CHESAPEAKE BEACH MD
20732-4217
US

IV. Provider business mailing address

4579 WILLOWS RD
CHESAPEAKE BEACH MD
20732-4217
US

V. Phone/Fax

Practice location:
  • Phone: 443-271-0688
  • Fax: 443-271-0688
Mailing address:
  • Phone: 443-271-0688
  • Fax: 443-271-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR086637
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: