Healthcare Provider Details

I. General information

NPI: 1164068250
Provider Name (Legal Business Name): KELLY ANN MARTIC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2019
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13551 WATERFORD PL
MIDLOTHIAN VA
23112-3929
US

IV. Provider business mailing address

1000 BOULDERS PKWY STE 102
NORTH CHESTERFIELD VA
23225-5515
US

V. Phone/Fax

Practice location:
  • Phone: 804-320-4243
  • Fax: 804-622-0552
Mailing address:
  • Phone: 804-320-4243
  • Fax: 804-622-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024178186
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: