Provider Demographics
NPI:1073274460
Name:KIELBAS, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:KIELBAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:2855 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:VA
Practice Address - Zip Code:23692-6501
Practice Address - Country:US
Practice Address - Phone:757-968-5700
Practice Address - Fax:757-968-5717
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008728363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program