=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073402707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIARA CAMILA DOUGLAS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2025
-----------------------------------------------------
Last Update Date | 01/19/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2405 ATHERHOLT RD
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24501-2184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-363-4133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1810 BROADWAY ST UNIT 102
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24501-5605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-748-9035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 0110011293
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------