Provider Demographics
NPI:1447082474
Name:COLLETTI, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:COLLETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 CIRCLE BROOK DR APT K
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8234
Mailing Address - Country:US
Mailing Address - Phone:703-789-6524
Mailing Address - Fax:
Practice Address - Street 1:101 ELM AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2222
Practice Address - Country:US
Practice Address - Phone:540-985-8483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program