Provider Demographics
NPI:1164492138
Name:BARRIAULT, KELLY GAIL (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GAIL
Last Name:BARRIAULT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MELTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1035 CHAMPIONS WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3762
Mailing Address - Country:US
Mailing Address - Phone:757-394-1540
Mailing Address - Fax:757-967-0793
Practice Address - Street 1:109 WIMBLEDON SQ
Practice Address - Street 2:STE. E
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4945
Practice Address - Country:US
Practice Address - Phone:757-547-9830
Practice Address - Fax:757-548-0721
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002088363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164492138Medicaid
VA008861M97Medicare ID - Type Unspecified
VAQ54750Medicare UPIN