Healthcare Provider Details

I. General information

NPI: 1184134140
Provider Name (Legal Business Name): KELLI FORSYTH MILLICAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 64881
BALTIMORE MD
21264-4881
US

V. Phone/Fax

Practice location:
  • Phone: 410-448-6400
  • Fax:
Mailing address:
  • Phone: 410-448-6400
  • Fax: 410-448-6296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085006375
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006375
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085006375
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0009685
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: