Healthcare Provider Details

I. General information

NPI: 1396117180
Provider Name (Legal Business Name): KAYLIE E WREN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

1033 28TH ST
NEWPORT NEWS VA
23607-4233
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7990
  • Fax:
Mailing address:
  • Phone: 757-952-2160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005110
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: