Provider Demographics
NPI:1538683479
Name:KELLY, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KELLY
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 1:505 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5020
Mailing Address - Country:US
Mailing Address - Phone:410-341-3420
Mailing Address - Fax:410-341-3397
Practice Address - Street 1:505 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5020
Practice Address - Country:US
Practice Address - Phone:410-341-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR228276363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health