Provider Demographics
NPI:1083661151
Name:PETRONIS, KELLI A (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:A
Last Name:PETRONIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:A
Other - Last Name:MAIERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:601 CHILDRENS LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1971
Mailing Address - Country:US
Mailing Address - Phone:757-668-9222
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-9222
Practice Address - Fax:757-668-7568
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233589207L00000X, 207PP0204X, 208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006739105Medicaid
PA1010661080001Medicaid
NC89066C4Medicaid
MD403654900Medicaid
NC89066C4Medicaid
PA1010661080001Medicaid