Healthcare Provider Details

I. General information

NPI: 1336578947
Provider Name (Legal Business Name): KELLY LLEWELLYN CRNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9093 RIDGEFIELD DR #104
FREDERICK MD
21701-6710
US

IV. Provider business mailing address

9115 SYCAMORE CT
UNION BRIDGE MD
21791-7560
US

V. Phone/Fax

Practice location:
  • Phone: 301-682-4100
  • Fax: 301-682-9100
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR143168
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: