Provider Demographics
NPI:1295152734
Name:BLOSSER, KELLY (CRNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BLOSSER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 KNOPP RD
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-1614
Mailing Address - Country:US
Mailing Address - Phone:410-328-9503
Mailing Address - Fax:
Practice Address - Street 1:1117 KNOPP RD
Practice Address - Street 2:
Practice Address - City:JARRETTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21084-1614
Practice Address - Country:US
Practice Address - Phone:410-328-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-22
Last Update Date:2014-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR134812363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care