Provider Demographics
NPI:1700213626
Name:FARWELL, KELLEY ELIZABETH (MSED, ATC, CSCS)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:ELIZABETH
Last Name:FARWELL
Suffix:
Gender:F
Credentials:MSED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 SYCAMORE GLEN LN
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2297
Mailing Address - Country:US
Mailing Address - Phone:774-239-6398
Mailing Address - Fax:
Practice Address - Street 1:8614 SYCAMORE GLEN LN
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-2297
Practice Address - Country:US
Practice Address - Phone:774-239-6398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-09
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260016662255A2300X
MDA00006182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer