Healthcare Provider Details

I. General information

NPI: 1497888226
Provider Name (Legal Business Name): ELIZABETH ANNE VAN DERMARK CRNP-A, WH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH WHITTINGTON

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 THOMAS JOHNSON DR SUITE C
FREDERICK MD
21702-4895
US

IV. Provider business mailing address

11350 MCCORMICK RD EXECUTIVE PLAZA 1, SUITE 501
HUNT VALLEY MD
21031-1002
US

V. Phone/Fax

Practice location:
  • Phone: 301-620-0012
  • Fax: 301-620-9687
Mailing address:
  • Phone: 301-620-0012
  • Fax: 301-620-9687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR086553
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR086553
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: