Provider Demographics
NPI:1215002290
Name:KEARLEY, MARY ANN (APRN)
Entity Type:Individual
Prefix:MS
First Name:MARY ANN
Middle Name:
Last Name:KEARLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 COLLEGE PARK SQ
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3609
Mailing Address - Country:US
Mailing Address - Phone:757-420-0530
Mailing Address - Fax:757-420-0488
Practice Address - Street 1:6465 COLLEGE PARK SQ
Practice Address - Street 2:SUITE 210
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3609
Practice Address - Country:US
Practice Address - Phone:757-420-0530
Practice Address - Fax:757-420-0488
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001342101YP2500X
VA0015000183364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010060389Medicaid
VAVV1643AMedicare PIN