Healthcare Provider Details

I. General information

NPI: 1164713608
Provider Name (Legal Business Name): KELLY DANIELLE RYAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 FRANKLIN SQUARE DR DEPT OF FAMILY MEDICINE
BALTIMORE MD
21237-3901
US

IV. Provider business mailing address

9000 FRANKLIN SQUARE DR DEPT OF FAMILY MEDICINE
BALTIMORE MD
21237-3901
US

V. Phone/Fax

Practice location:
  • Phone: 443-777-2034
  • Fax:
Mailing address:
  • Phone: 443-777-2034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberH78106
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: