Healthcare Provider Details

I. General information

NPI: 1659751097
Provider Name (Legal Business Name): KELSEY THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 08/22/2023
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST, BLALOCK 1410
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

600 N WOLFE ST, BLALOCK 1410
BALTIMORE MD
21287-0005
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-1675
  • Fax: 410-955-8309
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number106623
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: