Provider Demographics
NPI:1235231630
Name:KELLY, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:269 PENINSULA FARM RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-1013
Mailing Address - Country:US
Mailing Address - Phone:410-518-9808
Mailing Address - Fax:410-518-9842
Practice Address - Street 1:269 PENINSULA FARM RD
Practice Address - Street 2:SUITE F
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-1013
Practice Address - Country:US
Practice Address - Phone:410-518-9808
Practice Address - Fax:410-518-9842
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD21616208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD790131300Medicaid
D78095Medicare UPIN