Provider Demographics
NPI:1104013549
Name:STANLEY, KELLIE ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:STANLEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 MARSH RD
Mailing Address - Street 2:STORE 505
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4581
Mailing Address - Country:US
Mailing Address - Phone:302-793-0432
Mailing Address - Fax:302-793-0400
Practice Address - Street 1:3465 BOX HILL CORPORATE CENTER DR
Practice Address - Street 2:STE G
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1261
Practice Address - Country:US
Practice Address - Phone:410-569-4806
Practice Address - Fax:410-568-5474
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05678261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5070-0090OtherCARE FIRST
2191733361OtherCHAMPUS TRICARE
3316154000OtherIBC AMERIHEALTH
92838701OtherCARE FIRST
214147OtherJOHNS HOPKINS
92838701OtherCARE FIRST
2191733361OtherCHAMPUS TRICARE