Healthcare Provider Details

I. General information

NPI: 1134480353
Provider Name (Legal Business Name): MELISSA A KELLNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0 AVENUE D BUILDING 24, ROOM 5
PERRY POINT MD
21902-1003
US

IV. Provider business mailing address

9018 HEDGEROW WAY
BALTIMORE MD
21236-1918
US

V. Phone/Fax

Practice location:
  • Phone: 410-642-2411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: