1104013549 NPI number — KELLIE ANN STANLEY OTR/L

Table of content: KELLIE ANN STANLEY OTR/L (NPI 1104013549)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104013549 NPI number — KELLIE ANN STANLEY OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANLEY
Provider First Name:
KELLIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104013549
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1812 MARSH RD
Provider Second Line Business Mailing Address:
STORE 505
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19810-4581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-793-0432
Provider Business Mailing Address Fax Number:
302-793-0400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3465 BOX HILL CORPORATE CENTER DR
Provider Second Line Business Practice Location Address:
STE G
Provider Business Practice Location Address City Name:
ABINGDON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21009-1261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-569-4806
Provider Business Practice Location Address Fax Number:
410-568-5474
Provider Enumeration Date:
10/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  05678 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5070-0090 . This is a "CARE FIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2191733361 . This is a "CHAMPUS TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3316154000 . This is a "IBC AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 92838701 . This is a "CARE FIRST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 214147 . This is a "JOHNS HOPKINS" identifier . This identifiers is of the category "OTHER".




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