Provider Demographics
NPI:1639396914
Name:GOODMAN, KELLY A (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 SANGAMORE ROAD
Mailing Address - Street 2:SUITE 5207
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816-2529
Mailing Address - Country:US
Mailing Address - Phone:202-684-7167
Mailing Address - Fax:240-483-0441
Practice Address - Street 1:4701 SANGAMORE ROAD
Practice Address - Street 2:SUITE 5207
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-2529
Practice Address - Country:US
Practice Address - Phone:202-684-7167
Practice Address - Fax:240-483-0441
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN966360363LA2200X
MDR156558363LA2200X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413209200Medicaid
DC44330062OtherCAREFIRST
DC038745900Medicaid
VA1639396914Medicaid
VA1639396914Medicaid
DC038745900Medicaid