Provider Demographics
NPI:1053576397
Name:KELLEY, AMANDA G (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:G
Last Name:KELLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16621 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VA
Mailing Address - Zip Code:23192-2660
Mailing Address - Country:US
Mailing Address - Phone:804-883-5027
Mailing Address - Fax:804-883-5485
Practice Address - Street 1:16621 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VA
Practice Address - Zip Code:23192-2660
Practice Address - Country:US
Practice Address - Phone:804-883-5027
Practice Address - Fax:804-883-5027
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1521152W00000X
VA0618001767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MK1792452OtherDEA