Provider Demographics
NPI:1942708391
Name:KELLY, AMBER MARIE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:VA
Mailing Address - Zip Code:20159-0405
Mailing Address - Country:US
Mailing Address - Phone:571-271-8289
Mailing Address - Fax:
Practice Address - Street 1:LOUDOUN COUNTY PUBLIC SCHOOLS
Practice Address - Street 2:21000 EDUCATION CT
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148
Practice Address - Country:US
Practice Address - Phone:571-252-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0200X
VA225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty