Healthcare Provider Details

I. General information

NPI: 1689756520
Provider Name (Legal Business Name): RACHEL LOUISE KANCIANIC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS RACHEL LOUISE HUMPHREY

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 11/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SHADY LANE
WHITE STONE VA
22578-0046
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 804-435-3133
  • Fax: 804-435-1311
Mailing address:
  • Phone: 757-594-4006
  • Fax: 757-594-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110-002418
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: