Healthcare Provider Details

I. General information

NPI: 1356992853
Provider Name (Legal Business Name): KPNP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8353 DUSTY LN
MECHANICSVILLE VA
23116-2406
US

IV. Provider business mailing address

8353 DUSTY LN
MECHANICSVILLE VA
23116-2406
US

V. Phone/Fax

Practice location:
  • Phone: 804-617-0687
  • Fax: 804-282-9135
Mailing address:
  • Phone: 804-617-0687
  • Fax: 804-282-9135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN M PACK
Title or Position: AUTHORIZED OFFICIAL/OWNER
Credential: NP
Phone: 804-617-0687