Healthcare Provider Details

I. General information

NPI: 1376940247
Provider Name (Legal Business Name): KELI KRNJAIC BAINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 SEMINARY RD
ALEXANDRIA VA
22304-1535
US

IV. Provider business mailing address

3021 O ST NW
WASHINGTON DC
20007-3108
US

V. Phone/Fax

Practice location:
  • Phone: 703-766-9695
  • Fax:
Mailing address:
  • Phone: 202-657-7187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024172345
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1026687
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: