Healthcare Provider Details

I. General information

NPI: 1417274689
Provider Name (Legal Business Name): KELLY LORAINE DAUER PHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY LORAINE DAUER MD

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8230 BOONE BLVD STE 170
VIENNA VA
22182-2621
US

IV. Provider business mailing address

8230 BOONE BLVD STE 170
VIENNA VA
22182-2621
US

V. Phone/Fax

Practice location:
  • Phone: 571-310-2502
  • Fax: 571-413-0290
Mailing address:
  • Phone: 571-310-2502
  • Fax: 571-413-0290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101273373
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number185401
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberFE60464961
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number0101273373
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: