Provider Demographics
NPI:1386201648
Name:PLEMMONS, KELLI ANNE (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANNE
Last Name:PLEMMONS
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:ANNE
Other - Last Name:THIEDERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1033 W MASTERS DR
Mailing Address - Street 2:
Mailing Address - City:CROSS JUNCTION
Mailing Address - State:VA
Mailing Address - Zip Code:22625-2447
Mailing Address - Country:US
Mailing Address - Phone:509-531-3712
Mailing Address - Fax:
Practice Address - Street 1:1460 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-5195
Practice Address - Country:US
Practice Address - Phone:540-545-6505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260031542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer