Healthcare Provider Details

I. General information

NPI: 1063339323
Provider Name (Legal Business Name): KELLY TEODORO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 AIKEN ST
STAUNTON VA
24401-2001
US

IV. Provider business mailing address

1441 AIKEN ST
STAUNTON VA
24401-2001
US

V. Phone/Fax

Practice location:
  • Phone: 206-499-9476
  • Fax:
Mailing address:
  • Phone: 206-499-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024197842
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: