Provider Demographics
NPI:1164633293
Name:SIDDLE, JENNIFER ELIZABETH (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:SIDDLE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:ELIZABETH
Other - Last Name:SIDDLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-2704
Mailing Address - Fax:
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-4600
Practice Address - Fax:410-601-8448
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR231096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA342540717Medicaid
MDR231096OtherSTATE LICENSE