Provider Demographics
NPI:1417274689
Name:PHAM, KELLY LORAINE DAUER (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LORAINE DAUER
Last Name:PHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LORAINE
Other - Last Name:DAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8230 BOONE BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2621
Mailing Address - Country:US
Mailing Address - Phone:571-310-2502
Mailing Address - Fax:571-413-0290
Practice Address - Street 1:8230 BOONE BLVD STE 170
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2621
Practice Address - Country:US
Practice Address - Phone:571-310-2502
Practice Address - Fax:571-413-0290
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101273373208100000X, 2081P0010X
DC185401208100000X
WAFE604649612081P0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program