Provider Demographics
NPI:1902555154
Name:KELLY, KAYLYN MARIE (RN)
Entity Type:Individual
Prefix:
First Name:KAYLYN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1223
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23109-1223
Mailing Address - Country:US
Mailing Address - Phone:804-384-2008
Mailing Address - Fax:
Practice Address - Street 1:5372B OLD VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:SALUDA
Practice Address - State:VA
Practice Address - Zip Code:23149
Practice Address - Country:US
Practice Address - Phone:804-758-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001287908163WE0003X, 163WP0807X, 2080P0006X, 163W00000X
171M00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001287908OtherRN MULTISTATE COMPACT LICENSE