MEDICARE: STEPHANIE RAE GILLIS MS, NP-C, CRNP

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	363LF0000X	Family Nurse Practitioner	R169531	MD

General Provider Information

NPI Number	:	1790069490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE RAE GILLIS MS, NP-C, CRNP

Provider Business Mailing Address
First Line	:	3159 PINE ORCHARD LN APT 302
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-4223
Country	:	US
Telephone Number	:	443-420-8391
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 CENTENNIAL LN
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3600
Country	:	US
Telephone Number	:	866-389-2727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2011
Last Update Date	:	02/01/2022

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