Healthcare Provider Details

I. General information

NPI: 1821205378
Provider Name (Legal Business Name): KELLI ANN KERNEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 SPOTSYLVANIA AVENUE SUITE 201
FREDRICKSBURG VA
22408-8606
US

IV. Provider business mailing address

2702 LAKEVIEW PARKWAY
LOCUST GROVE VA
22508-5667
US

V. Phone/Fax

Practice location:
  • Phone: 540-741-3770
  • Fax: 540-741-3775
Mailing address:
  • Phone: 540-972-2402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306601619
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: