Healthcare Provider Details

I. General information

NPI: 1780175240
Provider Name (Legal Business Name): SHANNON KELLY WILL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 M ST NW STE 316
WASHINGTON DC
20037-1449
US

IV. Provider business mailing address

4 SPRING KNOLL CT
LUTHERVILLE MD
21093-3981
US

V. Phone/Fax

Practice location:
  • Phone: 202-659-2673
  • Fax:
Mailing address:
  • Phone: 443-846-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: