Provider Demographics
NPI:1952829251
Name:TRUSSELL, KELLY ANN (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6914 HOLABIRD AVE
Mailing Address - Street 2:
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222-1747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3350 WILKENS AVE STE 303
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-4618
Practice Address - Country:US
Practice Address - Phone:410-368-1026
Practice Address - Fax:410-368-1047
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MD28373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist