Healthcare Provider Details

I. General information

NPI: 1770764870
Provider Name (Legal Business Name): KELLY J VASQUENZA C.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE STREET BLALOCK 904
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

P.O. BOX 64382
BALTIMORE MD
21264-4382
US

V. Phone/Fax

Practice location:
  • Phone: 410-614-6222
  • Fax:
Mailing address:
  • Phone: 410-933-5474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberR127273
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20010086
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR127273
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: