Provider Demographics
NPI:1164091260
Name:GINESTRO, KELSEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GINESTRO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3346
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:19415 DEERFIELD AVENUE, SUITE 314
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8427
Practice Address - Country:US
Practice Address - Phone:703-723-7171
Practice Address - Fax:703-723-7176
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017440810001Medicaid
VA1164091260Medicaid