Basic Information
| Provider Information | |||||||||
| NPI: | 1104013549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1812 MARSH RD | ||||||||
| Address2: | STORE 505 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198104581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027930432 | ||||||||
| FaxNumber: | 3027930400 | ||||||||
| Practice Location | |||||||||
| Address1: | 3465 BOX HILL CORPORATE CENTER DR | ||||||||
| Address2: | STE G | ||||||||
| City: | ABINGDON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210091261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105694806 | ||||||||
| FaxNumber: | 4105685474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 12/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 05678 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 5070-0090 | 01 | CARE FIRST | OTHER | 2191733361 | 01 | CHAMPUS TRICARE | OTHER | 3316154000 | 01 | IBC AMERIHEALTH | OTHER | 92838701 | 01 | CARE FIRST | OTHER | 214147 | 01 | JOHNS HOPKINS | OTHER |