=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831508829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLI K MCCALLUM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2014
-----------------------------------------------------
Last Update Date | 01/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3721 CHESMONT AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21206-5041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-600-0105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3721 CHESMONT AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21206-5041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-600-0105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. KELLI MCCALLUM
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 443-600-0105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | R177915
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | R177915
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------