Provider Demographics
NPI:1841474020
Name:MEEHAN, KELLY MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:MEEHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MICHELLE
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:309 RUCKER PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22301-2521
Mailing Address - Country:US
Mailing Address - Phone:703-922-1000
Mailing Address - Fax:
Practice Address - Street 1:6501 LOISDALE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1826
Practice Address - Country:US
Practice Address - Phone:703-922-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-23
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253473208600000X
MDD0084668208600000X
DCMD045780208600000X
GA062571208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery