Healthcare Provider Details

I. General information

NPI: 1003990441
Provider Name (Legal Business Name): KELLY OLIVER SPANN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SENTARA CIR STE 320
WILLIAMSBURG VA
23188-5716
US

IV. Provider business mailing address

400 SENTARA CIR STE 320
WILLIAMSBURG VA
23188-5716
US

V. Phone/Fax

Practice location:
  • Phone: 757-345-4800
  • Fax: 757-345-4801
Mailing address:
  • Phone: 757-345-4800
  • Fax: 757-345-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024165415
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: