Provider Demographics
NPI:1730582198
Name:FUQUA, KELLI (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:FUQUA
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 GREENSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-1310
Mailing Address - Country:US
Mailing Address - Phone:302-293-1840
Mailing Address - Fax:
Practice Address - Street 1:3825 GREENSPRING AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1310
Practice Address - Country:US
Practice Address - Phone:302-293-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07521225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist