Provider Demographics
NPI:1841320322
Name:KELLY, SUSAN ELLEN (NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELLEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:TRACYS LANDING
Mailing Address - State:MD
Mailing Address - Zip Code:20779-0339
Mailing Address - Country:US
Mailing Address - Phone:515-720-5199
Mailing Address - Fax:
Practice Address - Street 1:1715 N GEORGE MASON DR
Practice Address - Street 2:STE 305
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3609
Practice Address - Country:US
Practice Address - Phone:703-816-4152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166282363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAD94066Medicare UPIN