MEDICARE: KETAVIA

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1629936703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETAVIA

Provider Business Mailing Address
First Line	:	5309 COMMONWEALTH CENTRE PKWY STE 103
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2633
Country	:	US
Telephone Number	:	804-940-8959
Fax Number	:	804-308-3362

Provider Business Practice Location Address
First Line	:	5309 COMMONWEALTH CENTRE PKWY STE 105
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2633
Country	:	US
Telephone Number	:	804-940-8959
Fax Number	:	804-308-3362

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KEISHA LOPEZ
Credential	:	DNP
Telephone Number	:	804-308-3403

Provider Enumeration Date	:	01/15/2026
Last Update Date	:	01/19/2026

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1922472158 — MR. MICHAEL SHAWN WHITLEY JR. ATC
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1700457082 — VALERIE SUE MOHRMAN LCSW
Practice Location Address:

5309 COMMONWEALTH CENTRE PKWY STE 401
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Directions to “KETAVIA ” Practice Location

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