Provider Demographics
NPI:1538162516
Name:KELLEY, MAUREEN ANNE (CRNP)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:ANNE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6392 SHADOWSHAPE PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4527
Mailing Address - Country:US
Mailing Address - Phone:410-605-7621
Mailing Address - Fax:410-605-7691
Practice Address - Street 1:3900 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2108
Practice Address - Country:US
Practice Address - Phone:410-605-7621
Practice Address - Fax:410-605-7691
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR051063363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS49566Medicare UPIN