Provider Demographics
NPI:1295349603
Name:KELLEY, STACY E (LMT)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:E
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 THALIA STATION CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1752
Mailing Address - Country:US
Mailing Address - Phone:757-559-4544
Mailing Address - Fax:
Practice Address - Street 1:312 THALIA STATION CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1752
Practice Address - Country:US
Practice Address - Phone:757-559-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019007831225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist