Healthcare Provider Details

I. General information

NPI: 1053348763
Provider Name (Legal Business Name): KATHLEEN R KELLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3299 WOODBURN RD SUITE 230
ANNANDALE VA
22003-1275
US

IV. Provider business mailing address

3300 GALLOWS RD PHYSICIAN BILLING
FALLS CHURCH VA
22042-3307
US

V. Phone/Fax

Practice location:
  • Phone: 703-205-2600
  • Fax: 703-205-2624
Mailing address:
  • Phone: 703-776-1110
  • Fax: 703-776-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101031289
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: