Provider Demographics
NPI:1518329366
Name:NIXON, KELLY J (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:NIXON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 WATERFORD LAKE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3994
Mailing Address - Country:US
Mailing Address - Phone:804-249-8277
Mailing Address - Fax:042-499-6908
Practice Address - Street 1:2820 WATERFORD LAKE DR STE 103
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3994
Practice Address - Country:US
Practice Address - Phone:804-249-8277
Practice Address - Fax:804-249-9690
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024390225100000X
WVPT003484225100000X
VA2305210073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherMEDICARE GROUP PTAN
VA1518329366OtherMEDICAID QMB PROVIDER ID
VAQ53138AMedicare PIN