Healthcare Provider Details

I. General information

NPI: 1194978957
Provider Name (Legal Business Name): JAN FAY KRESS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17305 SOPER ST
POOLESVILLE MD
20837-2110
US

IV. Provider business mailing address

17305 SOPER ST
POOLESVILLE MD
20837-2110
US

V. Phone/Fax

Practice location:
  • Phone: 202-957-4480
  • Fax:
Mailing address:
  • Phone: 202-957-4480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT141
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: