Provider Demographics
NPI:1356996011
Name:KELLY, ALLISON
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2373
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20604
Mailing Address - Country:US
Mailing Address - Phone:301-374-8895
Mailing Address - Fax:240-270-7256
Practice Address - Street 1:4 INDUSTRIAL PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2060
Practice Address - Country:US
Practice Address - Phone:240-925-4199
Practice Address - Fax:240-270-7256
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR5457374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty