Provider Demographics
NPI:1821492067
Name:BOARDMAN, KELLY ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ASHLEY
Last Name:BOARDMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 PURITAN CT
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2439
Mailing Address - Country:US
Mailing Address - Phone:404-326-2826
Mailing Address - Fax:
Practice Address - Street 1:19415 DEERFIELD AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8452
Practice Address - Country:US
Practice Address - Phone:703-729-9220
Practice Address - Fax:703-858-3529
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004747363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1821492067Medicaid
VA30016805880001Medicaid