Provider Demographics
NPI:1275102105
Name:KEITH, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:
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 2154
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-2154
Mailing Address - Country:US
Mailing Address - Phone:804-480-2151
Mailing Address - Fax:804-577-4340
Practice Address - Street 1:87 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-8501
Practice Address - Country:US
Practice Address - Phone:804-480-2151
Practice Address - Fax:804-577-4340
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-211723374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2HCO-211723OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH