Healthcare Provider Details

I. General information

NPI: 1225487861
Provider Name (Legal Business Name): KELLY MARIE HEYWARD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2016
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7067 COLUMBIA GATEWAY DR
COLUMBIA MD
21046-3407
US

IV. Provider business mailing address

5401 BELAIR RD
BALTIMORE MD
21206-4265
US

V. Phone/Fax

Practice location:
  • Phone: 410-929-7225
  • Fax: 443-333-5434
Mailing address:
  • Phone: 667-303-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR157850
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: