Provider Demographics
NPI:1427421411
Name:MITCHELL, KELLY LEE (PA-C, MMS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:MITCHELL
Suffix:
Gender:
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 TOWN CENTER DR STE 130
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5898
Mailing Address - Country:US
Mailing Address - Phone:703-689-2050
Mailing Address - Fax:
Practice Address - Street 1:1860 TOWN CENTER DR STE 130
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5898
Practice Address - Country:US
Practice Address - Phone:703-689-2050
Practice Address - Fax:703-689-2080
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110005101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant