Healthcare Provider Details

I. General information

NPI: 1053953919
Provider Name (Legal Business Name): KELLY NICOLE STEPHENS FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17094 FERRY DOCK RD
KING GEORGE VA
22485-6101
US

IV. Provider business mailing address

17094 FERRY DOCK RD
KING GEORGE VA
22485-6101
US

V. Phone/Fax

Practice location:
  • Phone: 540-413-1509
  • Fax: 540-675-4326
Mailing address:
  • Phone: 540-413-1509
  • Fax: 540-675-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024178294
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024178294
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: