Healthcare Provider Details

I. General information

NPI: 1346590361
Provider Name (Legal Business Name): MARTHA SUZANNE KELLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTHA SUZANNE ROSE FNP

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 RIDGEBROOK RD STE 300
SPARKS MD
21152-9477
US

IV. Provider business mailing address

909 RIDGEBROOK RD STE 300
SPARKS MD
21152-9477
US

V. Phone/Fax

Practice location:
  • Phone: 441-383-9300
  • Fax:
Mailing address:
  • Phone: 441-383-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0027774
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.397302
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: