Provider Demographics
NPI:1861433088
Name:KELLEY, COLLEEN DENISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:DENISE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12255 FAIR LAKES PKWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3952
Mailing Address - Country:US
Mailing Address - Phone:703-934-5700
Mailing Address - Fax:
Practice Address - Street 1:11234 LEATHERWOOD DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-4607
Practice Address - Country:US
Practice Address - Phone:703-391-0758
Practice Address - Fax:703-391-0758
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840732363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006968M92Medicare ID - Type Unspecified