Provider Demographics
NPI:1679292007
Name:KELLEY, REBECCA JANE (DNP, CRNP, A-GNP-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DNP, CRNP, A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 CAMPBELL DR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-2774
Mailing Address - Country:US
Mailing Address - Phone:765-914-6821
Mailing Address - Fax:
Practice Address - Street 1:345 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2123
Practice Address - Country:US
Practice Address - Phone:765-914-6821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR177796363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health