Healthcare Provider Details

I. General information

NPI: 1487140950
Provider Name (Legal Business Name): KANESHA MONIQUE GILLYARD DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2018
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 KNELLS RIDGE BLVD
CHESAPEAKE VA
23320-6607
US

IV. Provider business mailing address

70 KNELLS RIDGE BLVD
CHESAPEAKE VA
23320-6607
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax: 757-251-5262
Mailing address:
  • Phone: 757-722-9961
  • Fax: 757-251-5262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301453
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number344261
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number692102
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001437
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: