Healthcare Provider Details

I. General information

NPI: 1285048066
Provider Name (Legal Business Name): KELLI YOUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14260 WARWICK BLVD
NEWPORT NEWS VA
23602-3716
US

IV. Provider business mailing address

14260 WARWICK BLVD
NEWPORT NEWS VA
23602-3716
US

V. Phone/Fax

Practice location:
  • Phone: 757-874-1924
  • Fax: 757-874-1084
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202212579
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: