Provider Demographics
NPI:1336578947
Name:LLEWELLYN, KELLY (CRNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LLEWELLYN
Suffix:
Gender:F
Credentials:CRNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 SYCAMORE CT
Mailing Address - Street 2:
Mailing Address - City:UNION BRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21791-7560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9093 RIDGEFIELD DR
Practice Address - Street 2:#104
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6710
Practice Address - Country:US
Practice Address - Phone:301-682-4100
Practice Address - Fax:301-682-9100
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR143168363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580508Medicaid
MD926580505Medicaid
MD926580505Medicaid
MD926580508Medicaid