Healthcare Provider Details

I. General information

NPI: 1841320322
Provider Name (Legal Business Name): SUSAN ELLEN KELLY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 N GEORGE MASON DR STE 305
ARLINGTON VA
22205-3609
US

IV. Provider business mailing address

PO BOX 339
TRACYS LANDING MD
20779-0339
US

V. Phone/Fax

Practice location:
  • Phone: 703-816-4152
  • Fax:
Mailing address:
  • Phone: 515-720-5199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0024166282
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: