Healthcare Provider Details

I. General information

NPI: 1265833099
Provider Name (Legal Business Name): AMANDA DIANE KALLAS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 THOMAS JOHNSON DR STE 202
FREDERICK MD
21702-4550
US

IV. Provider business mailing address

180 THOMAS JOHNSON DR STE 202
FREDERICK MD
21702-4550
US

V. Phone/Fax

Practice location:
  • Phone: 301-631-6877
  • Fax: 301-631-5211
Mailing address:
  • Phone: 301-631-6877
  • Fax: 301-631-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR178408
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: