Provider Demographics
NPI:1194580233
Name:FOOTEN, KELLY (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FOOTEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14555 FAIRVIEW HILL LN
Mailing Address - Street 2:
Mailing Address - City:CLEAR SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:21722-1249
Mailing Address - Country:US
Mailing Address - Phone:301-748-7341
Mailing Address - Fax:
Practice Address - Street 1:1141 OPAL CT
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5976
Practice Address - Country:US
Practice Address - Phone:301-791-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169068363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty