Provider Demographics
NPI:1700201829
Name:THOMPSON, KELLY D (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2296 OPITZ BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3345
Mailing Address - Country:US
Mailing Address - Phone:703-878-0924
Mailing Address - Fax:703-878-1037
Practice Address - Street 1:2296 OPITZ BLVD STE 230
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3345
Practice Address - Country:US
Practice Address - Phone:703-878-0924
Practice Address - Fax:703-878-1037
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant