Healthcare Provider Details

I. General information

NPI: 1053787184
Provider Name (Legal Business Name): KELLY INGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8527 MAYLAND DR 101
RICHMOND VA
23294-4753
US

IV. Provider business mailing address

8527 MAYLAND DR 101
RICHMOND VA
23294-4753
US

V. Phone/Fax

Practice location:
  • Phone: 804-346-5165
  • Fax: 804-346-5167
Mailing address:
  • Phone: 804-346-5165
  • Fax: 804-346-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009111
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: