Healthcare Provider Details

I. General information

NPI: 1659820074
Provider Name (Legal Business Name): KELLY KATHLEEN DAVIS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY SCOTT

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18109 PRINCE PHILIP DR
OLNEY MD
20832-1519
US

IV. Provider business mailing address

18109 PRINCE PHILIP DR
OLNEY MD
20832-1519
US

V. Phone/Fax

Practice location:
  • Phone: 888-805-4551
  • Fax: 202-364-5183
Mailing address:
  • Phone: 888-805-4551
  • Fax: 202-364-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR134802
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: