Healthcare Provider Details

I. General information

NPI: 1558709584
Provider Name (Legal Business Name): JEREMY GLEN KELLEMS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 MOUNTAIN RD
GLEN ALLEN VA
23060-1930
US

IV. Provider business mailing address

13700 N GAYTON RD
RICHMOND VA
23233-7017
US

V. Phone/Fax

Practice location:
  • Phone: 804-672-8725
  • Fax:
Mailing address:
  • Phone: 804-432-4133
  • Fax: 804-213-9783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0017141048
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024170856
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001209239
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: