Provider Demographics
NPI:1770764870
Name:VASQUENZA, KELLY J (CRNP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:J
Last Name:VASQUENZA
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:P.O. BOX 64382
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4382
Mailing Address - Country:US
Mailing Address - Phone:410-933-5474
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE STREET
Practice Address - Street 2:BLALOCK 904
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-614-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR127273163WP0000X, 367500000X
MD20010086363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WP0000XNursing Service ProvidersRegistered NursePain Management
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
T0910OtherJHH