Provider Demographics
NPI:1295867083
Name:WILEY, KATHLEEN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:WILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 CENTER DR
Mailing Address - Street 2:BLDG 14
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4105
Mailing Address - Country:US
Mailing Address - Phone:757-461-8039
Mailing Address - Fax:757-461-8821
Practice Address - Street 1:6345 CENTER DR
Practice Address - Street 2:BLDG 14
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4105
Practice Address - Country:US
Practice Address - Phone:757-461-8039
Practice Address - Fax:757-461-8821
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241366208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1295867082Medicaid