Healthcare Provider Details

I. General information

NPI: 1679114581
Provider Name (Legal Business Name): SUSAN M KELLY NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S CATON AVE
BALTIMORE MD
21229-5201
US

IV. Provider business mailing address

561 HOOK RD
WESTMINSTER MD
21157-5963
US

V. Phone/Fax

Practice location:
  • Phone: 667-234-6000
  • Fax:
Mailing address:
  • Phone: 315-430-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberR239962
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: