Provider Demographics
NPI:1417426867
Name:BOULIER, KELSEY AYNE (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:AYNE
Last Name:BOULIER
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7628 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1232
Practice Address - Country:US
Practice Address - Phone:410-802-1197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA0000588207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine