Healthcare Provider Details

I. General information

NPI: 1902369374
Provider Name (Legal Business Name): KATHLEEN CLANCY DO, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATE CLANCY

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

213 S JEFFERSON ST STE 1006
ROANOKE VA
24011-1713
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number0102209132
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: