Healthcare Provider Details

I. General information

NPI: 1295937407
Provider Name (Legal Business Name): KATHERINE ANN LAYBOURN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 RIVER RD
PETERSBURG VA
23804
US

IV. Provider business mailing address

1704 HANOVER AVE
RICHMOND VA
23220-3506
US

V. Phone/Fax

Practice location:
  • Phone: 804-722-4413
  • Fax:
Mailing address:
  • Phone: 804-355-4703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101840551
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: