Provider Demographics
NPI:1831643196
Name:KELLY, ANGELA MARIE (OTR/L)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 APRIL WAY
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3904
Mailing Address - Country:US
Mailing Address - Phone:571-839-1278
Mailing Address - Fax:
Practice Address - Street 1:1469 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-477-6393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007016225X00000X
VA0119-007016225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist