Provider Demographics
NPI:1821733684
Name:SCANLON, KRISTEN NOELLE
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:NOELLE
Last Name:SCANLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:NOELLE
Other - Last Name:CICCARELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 JONES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-4799
Mailing Address - Country:US
Mailing Address - Phone:301-295-9004
Mailing Address - Fax:
Practice Address - Street 1:4301 JONES BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4712
Practice Address - Country:US
Practice Address - Phone:301-295-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY677953390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program