Provider Demographics
NPI:1790582674
Name:KELLY-HEARN, KRISTA HELEN
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:HELEN
Last Name:KELLY-HEARN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11478 WHITESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:DE
Mailing Address - Zip Code:19956-3316
Mailing Address - Country:US
Mailing Address - Phone:302-245-8996
Mailing Address - Fax:
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-546-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0013136363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner