Healthcare Provider Details

I. General information

NPI: 1366203036
Provider Name (Legal Business Name): JACQUELINE RITA KELLY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 W LOMBARD ST
BALTIMORE MD
21201-1009
US

IV. Provider business mailing address

140 MARIE CIR
ASTON PA
19014-2268
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-2300
  • Fax: 410-706-5770
Mailing address:
  • Phone: 610-804-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR236041
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: