Basic Information
| Provider Information | |||||||||
| NPI: | 1760116354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELZ | ||||||||
| FirstName: | BREANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 BEVERLY RD | ||||||||
| Address2: | |||||||||
| City: | REISTERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211361928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102942272 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6501 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2022 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R215135 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.