Healthcare Provider Details

I. General information

NPI: 1922533090
Provider Name (Legal Business Name): KATHRYN FITZGERALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 UKROP WAY
WILLIAMSBURG VA
23185
US

IV. Provider business mailing address

3803 E STEEPLECHASE WAY APT H
WILLIAMSBURG VA
23188-7837
US

V. Phone/Fax

Practice location:
  • Phone: 802-578-5533
  • Fax:
Mailing address:
  • Phone: 802-578-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberAT1409
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003468
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126003095
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: