MEDICARE: KELLY OLIVER SPANN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024165415	VA

General Provider Information

NPI Number	:	1003990441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY OLIVER SPANN NP

Provider Business Mailing Address
First Line	:	400 SENTARA CIR STE 320
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-5716
Country	:	US
Telephone Number	:	757-345-4800
Fax Number	:	757-345-4801

Provider Business Practice Location Address
First Line	:	400 SENTARA CIR STE 320
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-5716
Country	:	US
Telephone Number	:	757-345-4800
Fax Number	:	757-345-4801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	06/03/2026

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