Healthcare Provider Details

I. General information

NPI: 1730934571
Provider Name (Legal Business Name): KELLY LYNN COMBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 W REDWOOD ST STE 600
BALTIMORE MD
21201-7000
US

IV. Provider business mailing address

240 AMBLESIDE DR APT SUITE
SEVERNA PARK MD
21146-1220
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2902
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010065
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: