Provider Demographics
NPI:1225696883
Name:RUPP, KELLY ELISE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELISE
Last Name:RUPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 KILLDEER LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:VA
Mailing Address - Zip Code:22821-9745
Mailing Address - Country:US
Mailing Address - Phone:540-879-4300
Mailing Address - Fax:
Practice Address - Street 1:15 KILLDEER LN
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:VA
Practice Address - Zip Code:22821-9745
Practice Address - Country:US
Practice Address - Phone:540-879-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110006777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program