1235231630 NPI number — JACQUELINE KELLY MD

Table of content: JACQUELINE KELLY MD (NPI 1235231630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235231630 NPI number — JACQUELINE KELLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1235231630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
269 PENINSULA FARM RD
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
ARNOLD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21012-1013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-518-9808
Provider Business Mailing Address Fax Number:
410-518-9842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
269 PENINSULA FARM RD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
ARNOLD
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21012-1013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-518-9808
Provider Business Practice Location Address Fax Number:
410-518-9842
Provider Enumeration Date:
09/05/2006

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: 208000000X , with the licence number:  D21616 , 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: 790131300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com