MEDICARE: KELLEEN THORNOCK PTA

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	225200000X	Physical Therapy Assistant	2306605237	VA

General Provider Information

NPI Number	:	1811632862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEEN THORNOCK PTA

Provider Business Mailing Address
First Line	:	14265 MIDLOTHIAN TPKE
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23113-6560
Country	:	US
Telephone Number	:	804-464-2323
Fax Number	:

Provider Business Practice Location Address
First Line	:	14265 MIDLOTHIAN TPKE
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23113-6560
Country	:	US
Telephone Number	:	804-464-2323
Fax Number	:	804-464-2313

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

Provider Enumeration Date	:	05/04/2022
Last Update Date	:	05/04/2022

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Directions to “ KELLEEN THORNOCK PTA” Practice Location

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