Provider Demographics
NPI:1417957531
Name:CAMARDA, KELLY MITCHELL (MED)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MITCHELL
Last Name:CAMARDA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:743 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1803
Mailing Address - Country:US
Mailing Address - Phone:434-799-6288
Mailing Address - Fax:434-797-3685
Practice Address - Street 1:2104 LANGHORNE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1424
Practice Address - Country:US
Practice Address - Phone:434-528-4245
Practice Address - Fax:434-528-3685
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001139231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA103114OtherMEDICARE PALMETTO GBA PTAN (DANNY W. GNEWIKOW, PH.D., LLC)
VA1417957531Medicaid
VA640000112OtherMEDICARE PALMETTO GBA PTAN (AUDIOLOGY HEARING AID ASSOCIATES, INC.)
VA640004118OtherMEDICARE RAILROAD PTAN - DANNY W. GNEWIKOW, PH.D., LLC
VA640004119OtherMEDICARE RAILROAD PTAN - AUDIOLOGY HEARING AID ASSOCIATES, INC.
VA541361858OtherPIEDMONTCOMMUNITYHLTHPLAN
VA541361858OtherPRIMARY PHYSICIAN CARE-LY
VAP33302Medicare UPIN
VA540964595OtherPRIMARY PHYSICIAN CARE-DA
VA218161OtherANTHEM OF VA-LYN
VA248043OtherANTHEM OF VA - DANVILLE
VA640000113Medicare ID - Type UnspecifiedMEDICARE-TRAILBLAZER-DAN