Basic Information
| Provider Information | |||||||||
| NPI: | 1932267903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10110 MOLECULAR DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208507539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012792779 | ||||||||
| FaxNumber: | 3012792767 | ||||||||
| Practice Location | |||||||||
| Address1: | 10110 MOLECULAR DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208507539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012792779 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 04/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | LG0000347 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R227097 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.