MEDICARE: PEDIATRIC HEALTH CONNECT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center
2	363LP0200X	Pediatric Nurse Practitioner

General Provider Information

NPI Number	:	1285510685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC HEALTH CONNECT LLC

Provider Business Mailing Address
First Line	:	2421 VINEYARD LN
Second Line	:
City	:	CROFTON
State	:	MD
Zip	:	21114-1138
Country	:	US
Telephone Number	:	301-467-5033
Fax Number	:

Provider Business Practice Location Address
First Line	:	1302 CRONSON BLVD STE J
Second Line	:
City	:	CROFTON
State	:	MD
Zip	:	21114-2064
Country	:	US
Telephone Number	:	301-467-5033
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	CHAUNTELLE ELLIS
Credential	:	MSN, CRNP, CPNP-PC
Telephone Number	:	301-467-5033

Provider Enumeration Date	:	08/12/2025
Last Update Date	:	08/12/2025

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Directions to “PEDIATRIC HEALTH CONNECT LLC ” Practice Location

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