Healthcare Provider Details

I. General information

NPI: 1215110275
Provider Name (Legal Business Name): KRISTINA RENEE PEGRAM M.S.CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 VICTORY BLVD
YORKTOWN VA
23693
US

IV. Provider business mailing address

3540 VICTORY BLVD
YORKTOWN VA
23693-3641
US

V. Phone/Fax

Practice location:
  • Phone: 757-776-0736
  • Fax: 757-776-0737
Mailing address:
  • Phone: 757-776-0736
  • Fax: 757-776-0737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number2202004684
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202004684
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: