Healthcare Provider Details

I. General information

NPI: 1588258768
Provider Name (Legal Business Name): KATELYN LYNE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2021
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 CHARLES H DIMMOCK PKWY STE 100
COLONIAL HEIGHTS VA
23834-2990
US

IV. Provider business mailing address

15612 NEW GALE DR
MIDLOTHIAN VA
23112-5018
US

V. Phone/Fax

Practice location:
  • Phone: 804-520-1764
  • Fax: 804-616-4221
Mailing address:
  • Phone: 757-620-3847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024181020
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024181020
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: