MEDICARE: KRISTEN BOOTHBY FNP-C

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	0024179919	VA

General Provider Information

NPI Number	:	1912502220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN BOOTHBY FNP-C

Provider Business Mailing Address
First Line	:	2642 FLEET AVE
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23228-5136
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8239 MEADOWBRIDGE RD STE A
Second Line	:
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23116-2318
Country	:	US
Telephone Number	:	804-730-0800
Fax Number	:

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

Provider Enumeration Date	:	12/03/2020
Last Update Date	:	06/10/2021

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