Provider Demographics
NPI:1285510685
Name:PEDIATRIC HEALTH CONNECT LLC
Entity type:Organization
Organization Name:PEDIATRIC HEALTH CONNECT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CHAUNTELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, CRNP, CPNP-PC
Authorized Official - Phone:301-467-5033
Mailing Address - Street 1:2421 VINEYARD LN
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1138
Mailing Address - Country:US
Mailing Address - Phone:301-467-5033
Mailing Address - Fax:
Practice Address - Street 1:1302 CRONSON BLVD STE J
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2064
Practice Address - Country:US
Practice Address - Phone:301-467-5033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care