Provider Demographics
NPI:1154830594
Name:GORNTO, KATELIN MIKUTA (FNP)
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:MIKUTA
Last Name:GORNTO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7231 STAFFORD PARK DR
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-2311
Mailing Address - Country:US
Mailing Address - Phone:804-920-6847
Mailing Address - Fax:
Practice Address - Street 1:1122 N 25TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-5254
Practice Address - Country:US
Practice Address - Phone:804-355-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185568363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily