Provider Demographics
NPI:1932579893
Name:DEWYER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEWYER
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 1:2079 DANIEL STUART SQ
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3317
Mailing Address - Country:US
Mailing Address - Phone:703-491-5600
Mailing Address - Fax:703-491-1744
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-677-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-03
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172968174400000X
DCNP1025366363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No174400000XOther Service ProvidersSpecialist