Provider Demographics
NPI:1831508829
Name:KELLI K MCCALLUM
Entity type:Organization
Organization Name:KELLI K MCCALLUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALLUM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:443-600-0105
Mailing Address - Street 1:3721 CHESMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5041
Mailing Address - Country:US
Mailing Address - Phone:443-600-0105
Mailing Address - Fax:
Practice Address - Street 1:3721 CHESMONT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-5041
Practice Address - Country:US
Practice Address - Phone:443-600-0105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR177915261QC1500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health