Provider Demographics
NPI:1508278862
Name:SMALL, KELDENE
Entity Type:Individual
Prefix:
First Name:KELDENE
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7808 EMILYS WAY
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2465
Mailing Address - Country:US
Mailing Address - Phone:301-437-1297
Mailing Address - Fax:
Practice Address - Street 1:3312 AVENUE N # 30S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2645
Practice Address - Country:US
Practice Address - Phone:718-372-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program