Provider Demographics
NPI:1649912072
Name:KELLSTROM, KARLIE (PA)
Entity type:Individual
Prefix:
First Name:KARLIE
Middle Name:
Last Name:KELLSTROM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7571 COLD HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-1631
Mailing Address - Country:US
Mailing Address - Phone:804-746-9055
Mailing Address - Fax:
Practice Address - Street 1:7571 COLD HARBOR RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-1631
Practice Address - Country:US
Practice Address - Phone:703-965-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty