MEDICARE: KELLIE LOUGHRAN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN1031079	DC
2	363L00000X	Nurse Practitioner	0024177002	VA
3	363LF0000X	Family Nurse Practitioner	RN1031079	DC

General Provider Information

NPI Number	:	1497228159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE LOUGHRAN NP

Provider Business Mailing Address
First Line	:	4910 MASSACHUSETTS AVE NW STE 114
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20016-4384
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4910 MASSACHUSETTS AVE NW STE 114
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20016-4384
Country	:	US
Telephone Number	:	202-244-0812
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2019
Last Update Date	:	01/15/2019

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