Provider Demographics
NPI:1134789787
Name:KELLY, AMANDA ANSLEY
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANSLEY
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ANSLEY
Other - Last Name:VO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-5700
Mailing Address - Fax:781-744-5358
Practice Address - Street 1:120 EAGLE ROCK AVE STE 154
Practice Address - Street 2:
Practice Address - City:EAST HANOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-3168
Practice Address - Country:US
Practice Address - Phone:120-144-7477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11767700208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation