Healthcare Provider Details

I. General information

NPI: 1346776507
Provider Name (Legal Business Name): KENNERLY CLINTON PATRICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 EAST MARSHALL ST
RICHMOND VA
23298
US

IV. Provider business mailing address

1101 EAST MARSHALL ST. PO BOX 980160
RICHMOND VA
23298
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9682
  • Fax: 804-828-7567
Mailing address:
  • Phone: 804-828-9682
  • Fax: 804-828-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0102207203
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0102207203
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: