MEDICARE: DESIRE' KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	212926	MD

General Provider Information

NPI Number	:	1538597638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIRE' KELLY

Provider Business Mailing Address
First Line	:	7262 CRADLEROCK WAY
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-5069
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7262 CRADLEROCK WAY
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-5069
Country	:	US
Telephone Number	:	410-309-1070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	10/29/2013

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Directions to “ DESIRE' KELLY ” Practice Location

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