Healthcare Provider Details

I. General information

NPI: 1912881210
Provider Name (Legal Business Name): KATHLEEN MARIE MARCINEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5609 PATTERSON AVE STE C
RICHMOND VA
23226-2047
US

IV. Provider business mailing address

12710 MILL LOCK TER
MIDLOTHIAN VA
23113-2860
US

V. Phone/Fax

Practice location:
  • Phone: 804-223-3165
  • Fax: 804-223-3165
Mailing address:
  • Phone:
  • Fax: 804-223-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024194152
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: