Healthcare Provider Details

I. General information

NPI: 1194214924
Provider Name (Legal Business Name): KAITLIN C GUDGER CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 COMMERCIAL LN STE 220
SUFFOLK VA
23434
US

IV. Provider business mailing address

PO BOX 2114
SUFFOLK VA
23432-0114
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-2600
  • Fax:
Mailing address:
  • Phone: 757-618-3678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00001231765
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024176410
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: