Provider Demographics
NPI:1720156128
Name:KOMELASKY, ANN L (CRNP)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:L
Last Name:KOMELASKY
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:KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
Mailing Address - Street 2:2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNIT 6 W
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:11730 SUDLEY MANOR DRIVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2843
Practice Address - Country:US
Practice Address - Phone:703-257-3001
Practice Address - Fax:703-257-3133
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001069512363L00000X
VA0024069512363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P86483Medicare UPIN
003249K32Medicare ID - Type Unspecified