Basic Information
| Provider Information | |||||||||
| NPI: | 1194717983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEFANCIK | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | C.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 HOSPITAL DR | ||||||||
| Address2: | STE 803 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105538160 | ||||||||
| FaxNumber: | 4105538159 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 HOSPITAL DR | ||||||||
| Address2: | STE 803 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105538160 | ||||||||
| FaxNumber: | 4105538159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R120913 | MD | Y | Allopathic & Osteopathic Physicians | Surgery | 207T00000X | R120913 | MD | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207X00000X | R120913 | MD | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 363LF0000X | R120913 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 11583185 | 01 | CAQH | OTHER | 3405544 | 01 | CIGNA | OTHER | 546903-14 8756-0002 | 01 | CAREFIRST BLUE CROSS BLUE SHIELD | OTHER | 680010600 | 05 | MD | MEDICAID | 216966 | 01 | BRAVO HEALTH | OTHER |