Provider Demographics
NPI:1073507034
Name:PELKOFSKI, KATHLEEN MCEWAN (CANP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MCEWAN
Last Name:PELKOFSKI
Suffix:
Gender:F
Credentials:CANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:205 E. HIRST ROAD, SUITE 203
Practice Address - Street 2:
Practice Address - City:PURCELVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-6600
Practice Address - Country:US
Practice Address - Phone:540-751-0255
Practice Address - Fax:540-751-0466
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2023-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024056702363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073507034Medicaid
VA500012018OtherRR MEDICARE PIN
VA30015473310002Medicaid
S69477Medicare UPIN