Provider Demographics
NPI:1487421210
Name:KELLAM, LAEASHA (CRNP)
Entity type:Individual
Prefix:
First Name:LAEASHA
Middle Name:
Last Name:KELLAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11414 TOWER HILL LN
Mailing Address - Street 2:
Mailing Address - City:MARDELA SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:21837-2253
Mailing Address - Country:US
Mailing Address - Phone:443-880-1557
Mailing Address - Fax:
Practice Address - Street 1:7905 MALCOLM RD STE 205
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1749
Practice Address - Country:US
Practice Address - Phone:301-355-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202674363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily