Provider Demographics
NPI:1740503689
Name:KELLY GOODMAN NP & ASSOCIATES PC
Entity type:Organization
Organization Name:KELLY GOODMAN NP & ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:202-684-7167
Mailing Address - Street 1:4701 SANGAMORE ROAD
Mailing Address - Street 2:SUITE S207
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816-2529
Mailing Address - Country:US
Mailing Address - Phone:202-684-7167
Mailing Address - Fax:240-483-0441
Practice Address - Street 1:4701 SANGAMORE ROAD
Practice Address - Street 2:SUITE S207
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-2529
Practice Address - Country:US
Practice Address - Phone:202-684-7167
Practice Address - Fax:240-483-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-07
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LF0000X, 363LP2300X
MDR156558363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty