Provider Demographics
NPI:1417412636
Name:CARDILLO, KELLY MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:CARDILLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 COVE LANDING RD APT 304
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2679
Mailing Address - Country:US
Mailing Address - Phone:571-409-2089
Mailing Address - Fax:
Practice Address - Street 1:9229 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2504
Practice Address - Country:US
Practice Address - Phone:703-277-6611
Practice Address - Fax:703-383-0206
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603596208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation