Provider Demographics
NPI:1992760797
Name:KELLEY, KATHLEEN S (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:S
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801
Mailing Address - Country:US
Mailing Address - Phone:540-432-1700
Mailing Address - Fax:
Practice Address - Street 1:498 UNIVERSITY BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801
Practice Address - Country:US
Practice Address - Phone:540-432-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045174207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
3810003016OtherWV MEDICAID
VA1000870001OtherDME PROVIDER
VA1528917OtherCIGNA
VA010187257Medicaid
VA190072OtherANTHEM/BCBS
329798OtherSOUTHERN HEALTH
VA20552OtherOPTIMA
3810003016OtherWV MEDICAID
VA1528917OtherCIGNA