Provider Demographics
NPI:1376913178
Name:LONDON, KELLY M (AGPCNP, PMHNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:LONDON
Suffix:
Gender:F
Credentials:AGPCNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5408 DANVILLE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-3821
Mailing Address - Country:US
Mailing Address - Phone:561-703-4567
Mailing Address - Fax:
Practice Address - Street 1:801 N QUINCY ST STE 601
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1729
Practice Address - Country:US
Practice Address - Phone:410-823-6408
Practice Address - Fax:443-279-0738
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176165363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health