Provider Demographics
NPI:1174037444
Name:FOSTER, KELLY (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 MEADOW DR W
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-4132
Mailing Address - Country:US
Mailing Address - Phone:757-323-5139
Mailing Address - Fax:
Practice Address - Street 1:3108 TYRE NECK RD STE D
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703
Practice Address - Country:US
Practice Address - Phone:757-323-5139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-25
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA19006819225700000X
VA0019006819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist