Healthcare Provider Details

I. General information

NPI: 1700101862
Provider Name (Legal Business Name): KELLIE NOELLE JAMES CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N WASHINGTON ST STE 300
FALLS CHURCH VA
22046-3514
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 571-419-5645
  • Fax: 571-419-5641
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024187212
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number53-75106-122
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP023623
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: