Healthcare Provider Details

I. General information

NPI: 1093445231
Provider Name (Legal Business Name): KEVIN DONNELL LLANOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2022
Last Update Date: 06/11/2022
Certification Date: 06/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 STEED CT
CHESAPEAKE VA
23323-2843
US

IV. Provider business mailing address

2905 STEED CT
CHESAPEAKE VA
23323-2843
US

V. Phone/Fax

Practice location:
  • Phone: 757-292-5096
  • Fax:
Mailing address:
  • Phone: 757-292-5096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number2200665
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: