Provider Demographics
NPI:1205422375
Name:FEASTER, KELLY (AGACNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FEASTER
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 S EADS ST APT 505
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-3035
Mailing Address - Country:US
Mailing Address - Phone:516-644-7605
Mailing Address - Fax:
Practice Address - Street 1:10220 RIVER RD
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-4916
Practice Address - Country:US
Practice Address - Phone:240-499-8854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1043627363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care