Provider Demographics
NPI:1376035634
Name:CROAK, KELSEY LYNN (MED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:CROAK
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HOUSTON ST APT A
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-2417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2652
Practice Address - Country:US
Practice Address - Phone:540-464-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260020092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer