Provider Demographics
NPI:1538918859
Name:KELLY, AILEEN T (MD)
Entity type:Individual
Prefix:DR
First Name:AILEEN
Middle Name:T
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:AILEEN K
Other - Last Name:FOECKLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9509 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4311
Mailing Address - Country:US
Mailing Address - Phone:703-392-1470
Mailing Address - Fax:
Practice Address - Street 1:9509 PARK ST
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4311
Practice Address - Country:US
Practice Address - Phone:703-392-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045784208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics