Provider Demographics
NPI:1700218310
Name:MANAHAN, KELLEY M (NP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:M
Last Name:MANAHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8988 LORTON STATION BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4756
Mailing Address - Country:US
Mailing Address - Phone:703-780-2800
Mailing Address - Fax:703-780-0461
Practice Address - Street 1:8988 LORTON STATION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4756
Practice Address - Country:US
Practice Address - Phone:703-780-2800
Practice Address - Fax:703-780-0461
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171028363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health