Provider Demographics
NPI:1801481783
Name:WILLSON, KELLIE EVELYNN
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:EVELYNN
Last Name:WILLSON
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 1:34 W BRIAR DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-1240
Mailing Address - Country:US
Mailing Address - Phone:585-307-4916
Mailing Address - Fax:
Practice Address - Street 1:6251 OLD DOMINION DR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4827
Practice Address - Country:US
Practice Address - Phone:703-536-4344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant