Provider Demographics
NPI:1689286197
Name:NGENGE, KELLY AMIKE (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:AMIKE
Last Name:NGENGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BIERSTADT CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-6442
Mailing Address - Country:US
Mailing Address - Phone:512-788-8867
Mailing Address - Fax:
Practice Address - Street 1:107 BIERSTADT CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-6442
Practice Address - Country:US
Practice Address - Phone:512-788-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR226054363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health