Provider Demographics
NPI:1821492620
Name:CONNOLLY, KELAN OLIVER (DC)
Entity Type:Individual
Prefix:DR
First Name:KELAN
Middle Name:OLIVER
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4172
Mailing Address - Country:US
Mailing Address - Phone:443-255-4283
Mailing Address - Fax:
Practice Address - Street 1:545 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4172
Practice Address - Country:US
Practice Address - Phone:443-255-4283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557104111N00000X
VA471398119111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty