Healthcare Provider Details

I. General information

NPI: 1336136100
Provider Name (Legal Business Name): KATHRYN ANN KELLY D.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 TAPPAHANNOCK BLVD
TAPPAHANNOCK VA
22560-9352
US

IV. Provider business mailing address

PO BOX 606
TAPPAHANNOCK VA
22560-0606
US

V. Phone/Fax

Practice location:
  • Phone: 804-445-1015
  • Fax: 804-445-1435
Mailing address:
  • Phone: 804-445-1015
  • Fax: 804-445-1435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305204143
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: