Provider Demographics
NPI:1336136100
Name:KELLY, KATHRYN ANN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-0606
Mailing Address - Country:US
Mailing Address - Phone:804-445-1015
Mailing Address - Fax:804-445-1435
Practice Address - Street 1:1924 TAPPAHANNOCK BLVD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-9352
Practice Address - Country:US
Practice Address - Phone:804-445-1015
Practice Address - Fax:804-445-1435
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA259468OtherBCBS PROVIDER ID
GA006776C78Medicare ID - Type UnspecifiedRAILROAD MEDICARE PART B
VA259468OtherBCBS PROVIDER ID