Healthcare Provider Details

I. General information

NPI: 1922310713
Provider Name (Legal Business Name): ELLEN S LEIDER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN S DAVID NP

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 LIBERTY RD
RANDALLSTOWN MD
21133-3521
US

IV. Provider business mailing address

8494 ROBERTS RD
ELLICOTT CITY MD
21043-6011
US

V. Phone/Fax

Practice location:
  • Phone: 410-548-2343
  • Fax:
Mailing address:
  • Phone: 650-380-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR157119
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR157119
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: