Provider Demographics
NPI:1194214924
Name:GUDGER, KAITLIN C (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:C
Last Name:GUDGER
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2114
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23432-0114
Mailing Address - Country:US
Mailing Address - Phone:757-618-3678
Mailing Address - Fax:
Practice Address - Street 1:1005 COMMERCIAL LN STE 220
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-668-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00001231765208000000X
VA0024176410363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics