Provider Demographics
NPI:1164569687
Name:EPPS-ANDERSON, KELLY CHARRISE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CHARRISE
Last Name:EPPS-ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:703-331-0300
Mailing Address - Fax:
Practice Address - Street 1:8505 ARLINGTON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-698-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101255984207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06380OtherPALMETTO GBA MEDICARE OF VIRGINIA
DCG00773OtherNOVITAS MEDICARE
VAC08583OtherPALMETTO GBA OF VIRGINIA MANASSAS HEART
VAC09878OtherPALMETTO GBA OF VIRGINIA WARRENTON HEART
DC16042OtherNOVITAS MEDICARE MANASSAS HEART