Healthcare Provider Details

I. General information

NPI: 1750679429
Provider Name (Legal Business Name): CATHY KELLY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9950 COURTHOUSE RD
CHARLES CITY VA
23030-3434
US

IV. Provider business mailing address

9950 COURTHOUSE RD
CHARLES CITY VA
23030-3434
US

V. Phone/Fax

Practice location:
  • Phone: 804-829-6600
  • Fax: 804-829-6182
Mailing address:
  • Phone: 804-829-6600
  • Fax: 804-829-6182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number00024169432
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: