Provider Demographics
NPI:1568942506
Name:SILLAH, KEMELLA
Entity Type:Individual
Prefix:
First Name:KEMELLA
Middle Name:
Last Name:SILLAH
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 1:3949 BREAKWATER LN
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-4351
Mailing Address - Country:US
Mailing Address - Phone:213-270-4406
Mailing Address - Fax:
Practice Address - Street 1:6455 MACHINE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21005-2100
Practice Address - Country:US
Practice Address - Phone:410-278-5478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008927363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner