Healthcare Provider Details

I. General information

NPI: 1417426867
Provider Name (Legal Business Name): KELSEY AYNE BOULIER MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S HANOVER ST
BALTIMORE MD
21225-1232
US

IV. Provider business mailing address

7628 LAUREL DR
PASADENA MD
21122-1912
US

V. Phone/Fax

Practice location:
  • Phone: 410-802-1197
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberA0000588
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: