Healthcare Provider Details

I. General information

NPI: 1427584127
Provider Name (Legal Business Name): KELLEY WIESE PHD, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 UNIVERSITY DR
WINCHESTER VA
22601-5195
US

IV. Provider business mailing address

45912 SWALLOW TER
STERLING VA
20165-5889
US

V. Phone/Fax

Practice location:
  • Phone: 609-240-9651
  • Fax:
Mailing address:
  • Phone: 609-240-9651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: