Provider Demographics
NPI:1043339864
Name:KELLY, LINDA D
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:D
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 WILSON LN
Mailing Address - Street 2:
Mailing Address - City:WEEMS
Mailing Address - State:VA
Mailing Address - Zip Code:22576-2202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5372 B OLD VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23175
Practice Address - Country:US
Practice Address - Phone:804-758-5250
Practice Address - Fax:804-758-5183
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator