MEDICARE: KEVINA BOONE PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024180199	VA

General Provider Information

NPI Number	:	1225635683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVINA BOONE PMHNP

Provider Business Mailing Address
First Line	:	5025 TWELVEOAKS RD
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2835
Country	:	US
Telephone Number	:	757-303-4758
Fax Number	:

Provider Business Practice Location Address
First Line	:	5360 DISCOVERY PARK BLVD STE 201
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-2860
Country	:	US
Telephone Number	:	804-730-0432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2020
Last Update Date	:	10/07/2020

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