Healthcare Provider Details

I. General information

NPI: 1144292822
Provider Name (Legal Business Name): KELLY MAYA LATIMER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 FAIRFAX AVE STE 118
NORFOLK VA
23507-1914
US

IV. Provider business mailing address

825 FAIRFAX AVE STE 118
NORFOLK VA
23507-1914
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-5955
  • Fax: 757-446-8450
Mailing address:
  • Phone: 757-446-5955
  • Fax: 757-446-8450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101223148
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: