Provider Demographics
NPI:1457858300
Name:ANDERSON, KELLY R (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:R
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3863 MILL MOUNT CT
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-5047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10120 W BROAD ST STE F
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6709
Practice Address - Country:US
Practice Address - Phone:804-212-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-08
Last Update Date:2018-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175710363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily