Provider Demographics
NPI:1861178667
Name:ELLIS, NICHOLAS MCLEAN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MCLEAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4174 HOOPER RD
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:MD
Mailing Address - Zip Code:21776
Mailing Address - Country:US
Mailing Address - Phone:831-241-1458
Mailing Address - Fax:
Practice Address - Street 1:UNIV OF MARYLAND MEDICAL CTR, 22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:410-328-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD244221363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health