MEDICARE: MRS. KELLEY LYNN MYERS FNP

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	363LF0000X	Family Nurse Practitioner	R178372	MD

General Provider Information

NPI Number	:	1679822324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLEY LYNN MYERS FNP

Provider Business Mailing Address
First Line	:	11520 LITTLE PATUXENT PKWY
Second Line	:	CONDO #309
City	:	COLUMBIA
State	:	MD
Zip	:	21044-4335
Country	:	US
Telephone Number	:	410-852-4256
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 CENTENNIAL LN
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-3600
Country	:	US
Telephone Number	:	410-750-9439
Fax Number	:

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

Provider Enumeration Date	:	09/07/2012
Last Update Date	:	09/07/2012

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