Provider Demographics
NPI:1073843512
Name:STAFFORD, KELLY M (MS, ATC)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:M
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19716-2010
Mailing Address - Country:US
Mailing Address - Phone:302-831-2255
Mailing Address - Fax:
Practice Address - Street 1:631 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19716-2010
Practice Address - Country:US
Practice Address - Phone:302-831-8857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT7592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer