Healthcare Provider Details

I. General information

NPI: 1285395905
Provider Name (Legal Business Name): KIMBERLY SAMANTHA DOCTOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 KEMPSVILLE RD STE 100E
NORFOLK VA
23502-3920
US

IV. Provider business mailing address

850 KEMPSVILLE RD STE 100E
NORFOLK VA
23502-3920
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-5744
  • Fax: 757-261-0321
Mailing address:
  • Phone: 757-261-5744
  • Fax: 757-261-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008725
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: