Provider Demographics
NPI:1043536790
Name:KALLON, AGNES JENNIFER (CRNP)
Entity Type:Individual
Prefix:MS
First Name:AGNES
Middle Name:JENNIFER
Last Name:KALLON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9607 OXBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3035
Mailing Address - Country:US
Mailing Address - Phone:240-691-9840
Mailing Address - Fax:
Practice Address - Street 1:7300 HANOVER DR
Practice Address - Street 2:SUITE 301
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2202
Practice Address - Country:US
Practice Address - Phone:301-345-1800
Practice Address - Fax:301-345-3854
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR123473363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR123473OtherLICENSE