Healthcare Provider Details

I. General information

NPI: 1194717983
Provider Name (Legal Business Name): KELLEY J. STEFANCIK C.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 HOSPITAL DR STE 208
GLEN BURNIE MD
21061-5801
US

IV. Provider business mailing address

301 HOSPITAL DR STE 803
GLEN BURNIE MD
21061-5803
US

V. Phone/Fax

Practice location:
  • Phone: 410-553-8160
  • Fax: 410-553-8159
Mailing address:
  • Phone: 410-553-8160
  • Fax: 410-553-8159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR120913
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberR120913
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberR120913
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR120913
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: