Provider Demographics
NPI:1659844801
Name:WOJCIECHOWSKI, KELLY
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:WOJCIECHOWSKI
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 1:10826A SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8015 APPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-4174
Practice Address - Country:US
Practice Address - Phone:410-255-0102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR215373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily