Provider Demographics
NPI:1679943724
Name:TITTELFITZ, JENELLE (PA-C)
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:TITTELFITZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7611 RESERVE CIR
Mailing Address - Street 2:APT 004
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1646
Mailing Address - Country:US
Mailing Address - Phone:541-337-0142
Mailing Address - Fax:
Practice Address - Street 1:4451 PARLIAMENT PL STE G
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-1873
Practice Address - Country:US
Practice Address - Phone:301-459-9113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant