Provider Demographics
NPI:1821544818
Name:MARAH, KELLIE FAGBOWA
Entity Type:Individual
Prefix:MR
First Name:KELLIE
Middle Name:FAGBOWA
Last Name:MARAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6529 LANDOVER RD APT 102
Mailing Address - Street 2:
Mailing Address - City:CHEVERLY
Mailing Address - State:MD
Mailing Address - Zip Code:20785-1429
Mailing Address - Country:US
Mailing Address - Phone:240-706-1658
Mailing Address - Fax:
Practice Address - Street 1:1010 WISCONSIN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-3603
Practice Address - Country:US
Practice Address - Phone:202-955-8355
Practice Address - Fax:703-753-8793
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1028482163W00000X, 163WM0705X
MDR203641163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse