Provider Demographics
NPI:1073207064
Name:KELLEY, KC (DO)
Entity Type:Individual
Prefix:DR
First Name:KC
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 MEMORIAL AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2652
Mailing Address - Country:US
Mailing Address - Phone:143-420-0615
Mailing Address - Fax:
Practice Address - Street 1:2323 MEMORIAL AVE STE 10
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2652
Practice Address - Country:US
Practice Address - Phone:143-420-0615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116037899390200000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program