Healthcare Provider Details

I. General information

NPI: 1912568148
Provider Name (Legal Business Name): KELSEY S IVUSICH AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1590
US

IV. Provider business mailing address

PO BOX 64442
BALTIMORE MD
21264-4442
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-8141
  • Fax: 410-328-0177
Mailing address:
  • Phone: 410-328-8040
  • Fax: 443-462-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR186021
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: