Healthcare Provider Details

I. General information

NPI: 1821492067
Provider Name (Legal Business Name): KELLY ASHLEY BOARDMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 DEERFIELD AVE SUITE 213
LEESBURG VA
20176-8452
US

IV. Provider business mailing address

2623 PURITAN CT
HERNDON VA
20171-2439
US

V. Phone/Fax

Practice location:
  • Phone: 703-729-9220
  • Fax: 703-858-3529
Mailing address:
  • Phone: 404-326-2826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110004747
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: