Provider Demographics
NPI:1629650130
Name:KELLY, ANDREW T (ATC, NASM-CPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:T
Last Name:KELLY
Suffix:
Gender:M
Credentials:ATC, NASM-CPT
Other - Prefix:MR
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC, NAMS-CPT
Mailing Address - Street 1:14649 SPOTSWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3076
Mailing Address - Country:US
Mailing Address - Phone:757-753-7453
Mailing Address - Fax:
Practice Address - Street 1:254 MONROE DR
Practice Address - Street 2:
Practice Address - City:STANARDSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22973-2852
Practice Address - Country:US
Practice Address - Phone:434-939-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260008582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer