Provider Demographics
NPI:1639870652
Name:SPENCER, KELLY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6001
Mailing Address - Fax:703-443-8346
Practice Address - Street 1:21035 SYCOLIN ROAD, SUITE 180
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4311
Practice Address - Country:US
Practice Address - Phone:703-783-5673
Practice Address - Fax:703-297-3919
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186610363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017597090001Medicaid
VA1639870652Medicaid