MEDICARE: ELITE WEIGHTLOSS & TRT

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	261QM1300X	Multi-Specialty Clinic/Center
2	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1568283547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE WEIGHTLOSS & TRT

Provider Business Mailing Address
First Line	:	1604 RIDGESIDE DR STE B2
Second Line	:
City	:	MOUNT AIRY
State	:	MD
Zip	:	21771-5240
Country	:	US
Telephone Number	:	410-498-7055
Fax Number	:	410-862-4191

Provider Business Practice Location Address
First Line	:	1604 RIDGESIDE DR STE B2
Second Line	:
City	:	MOUNT AIRY
State	:	MD
Zip	:	21771-5240
Country	:	US
Telephone Number	:	410-498-7055
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. EMILIENNE NKEMAYIM
Credential	:	CRNP
Telephone Number	:	410-498-7055

Provider Enumeration Date	:	10/22/2024
Last Update Date	:	07/17/2025

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Directions to “ELITE WEIGHTLOSS & TRT ” Practice Location

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