MEDICARE: JOELLE MARY KELLY MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	2305207084	VA

General Provider Information

NPI Number	:	1447531066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOELLE MARY KELLY MSPT

Provider Business Mailing Address
First Line	:	2517 RAEFORD CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-7619
Country	:	US
Telephone Number	:	757-430-4126
Fax Number	:

Provider Business Practice Location Address
First Line	:	2517 RAEFORD CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-7619
Country	:	US
Telephone Number	:	757-430-4126
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2011
Last Update Date	:	09/09/2011

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