Healthcare Provider Details

I. General information

NPI: 1760642953
Provider Name (Legal Business Name): KELLY KENNETT LASTRAPES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY LYNN KENNETT M.D.

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST DEPT. OF PEDIATRICS:ONCOLOGY/HEMATOLOGY
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9605
  • Fax: 804-828-0504
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number0101251167
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101251167
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: