Provider Demographics
NPI:1194717983
Name:STEFANCIK, KELLEY J (CRNP)
Entity type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:J
Last Name:STEFANCIK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 HOSPITAL DR
Mailing Address - Street 2:STE 803
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5803
Mailing Address - Country:US
Mailing Address - Phone:410-553-8160
Mailing Address - Fax:410-553-8159
Practice Address - Street 1:255 HOSPITAL DR STE 208
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5801
Practice Address - Country:US
Practice Address - Phone:410-553-8160
Practice Address - Fax:410-553-8159
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR120913207T00000X, 207X00000X, 363LF0000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
216966OtherBRAVO HEALTH
3405544OtherCIGNA
11583185OtherCAQH
546903-14 8756-0002OtherCAREFIRST BLUE CROSS BLUE SHIELD
MD680010600Medicaid
216966OtherBRAVO HEALTH
3405544OtherCIGNA
MD165794ZEZTMedicare PIN