Healthcare Provider Details

I. General information

NPI: 1174851877
Provider Name (Legal Business Name): KRISTIN F. STORY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN G FOWLER PA

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 N 11TH ST FL 3
RICHMOND VA
23298-5002
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-7748
  • Fax: 804-827-0285
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003220
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: