Provider Demographics
NPI:1417166133
Name:KELLY, AMY ELIZABETH (COTA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10305 NAPOLEON ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-8023
Mailing Address - Country:US
Mailing Address - Phone:540-310-0142
Mailing Address - Fax:
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:540-785-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1014395282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital