Provider Demographics
NPI:1770101180
Name:KENDALL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KENDALL
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 1:1782 E REGENTS PARK RD
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2530
Mailing Address - Country:US
Mailing Address - Phone:856-220-5144
Mailing Address - Fax:
Practice Address - Street 1:1782 E REGENTS PARK RD
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2530
Practice Address - Country:US
Practice Address - Phone:856-220-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203305163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant