Provider Demographics
NPI:1558364778
Name:NOONAN, KELLIE JEAN FOX (CRNP)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:JEAN FOX
Last Name:NOONAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:KELLIE
Other - Middle Name:JEAN
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:
Practice Address - Street 1:635 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5021
Practice Address - Country:US
Practice Address - Phone:443-754-1675
Practice Address - Fax:883-449-3796
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR114595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
MDP91980Medicare UPIN
MDMF0952057OtherDEA