MEDICARE: MAUREEN ANNE KELLEY CRNP

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	363LP2300X	Primary Care Nurse Practitioner	R051063	MD

General Provider Information

NPI Number	:	1538162516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAUREEN ANNE KELLEY CRNP

Provider Business Mailing Address
First Line	:	6392 SHADOWSHAPE PL
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-4527
Country	:	US
Telephone Number	:	410-605-7621
Fax Number	:	410-605-7691

Provider Business Practice Location Address
First Line	:	3900 LOCH RAVEN BLVD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-2108
Country	:	US
Telephone Number	:	410-605-7621
Fax Number	:	410-605-7691

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	08/24/2012

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