Provider Demographics
NPI:1619650108
Name:ELY, KELLY JO (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:ELY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
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Mailing Address - Street 1:17343 BURCHETT LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERDAM
Mailing Address - State:VA
Mailing Address - Zip Code:23015-1779
Mailing Address - Country:US
Mailing Address - Phone:804-878-4651
Mailing Address - Fax:
Practice Address - Street 1:7101 JAHNKE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4017
Practice Address - Country:US
Practice Address - Phone:804-483-2380
Practice Address - Fax:804-483-2381
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0001292795207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease