Provider Demographics
NPI:1659820074
Name:DAVIS, KELLY KATHLEEN (CRNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHLEEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18109 PRINCE PHILIP DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1519
Mailing Address - Country:US
Mailing Address - Phone:888-805-4551
Mailing Address - Fax:202-364-5183
Practice Address - Street 1:18109 PRINCE PHILIP DR
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1519
Practice Address - Country:US
Practice Address - Phone:888-805-4551
Practice Address - Fax:202-364-5183
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR134802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCM800003OtherBCBS
MD633205600Medicaid
MDCM800003OtherBCBS