Provider Demographics
NPI:1851809420
Name:PENNOCK, KELLY (COTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PENNOCK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2238 WHITCOMB PL
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-1852
Mailing Address - Country:US
Mailing Address - Phone:540-840-2247
Mailing Address - Fax:540-840-2247
Practice Address - Street 1:1739 KIRBY RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4817
Practice Address - Country:US
Practice Address - Phone:800-451-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant