Individual
KELLY J. NIXON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT, DPT
Contact information
Practice address
2820 WATERFORD LAKE DR STE 103, MIDLOTHIAN, VA 23112-3994
(804) 249-8277
(804) 249-9690
Mailing address
2820 WATERFORD LAKE DR STE 103, MIDLOTHIAN, VA 23112-3994
(804) 249-8277
(042) 499-6908
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2305210073
VA
225100000X
Physical Therapist
PT003484
WV
225100000X
Physical Therapist
PT024390
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1518329366
MEDICAID QMB PROVIDER ID
VA
01
—
C05954
MEDICARE GROUP PTAN
VA
Enumeration date
03/22/2016
Last updated
08/02/2022
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