Healthcare Provider Details

I. General information

NPI: 1881153120
Provider Name (Legal Business Name): NICOLE ANEIROS KELLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE ANEIROS

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 SALEM CHURCH RD
FREDERICKSBURG VA
22407-6484
US

IV. Provider business mailing address

2632 SALEM CHURCH RD
FREDERICKSBURG VA
22407-6484
US

V. Phone/Fax

Practice location:
  • Phone: 540-899-3440
  • Fax:
Mailing address:
  • Phone: 540-899-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101277629
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: