Provider Demographics
NPI:1821538117
Name:FICKES, KELLY (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FICKES
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4231 MONUMENT WALL WAY
Mailing Address - Street 2:APT 453
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4231 MONUMENT WALL WAY
Practice Address - Street 2:APT 453
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-8433
Practice Address - Country:US
Practice Address - Phone:240-925-1797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260006932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer