Provider Demographics
NPI:1417114638
Name:RICHARDSON, GINGER PETTENGILL (NP)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:PETTENGILL
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:757-594-2195
Practice Address - Street 1:16681 PULLER HIGHWAY
Practice Address - Street 2:
Practice Address - City:DELTAVILLE
Practice Address - State:VA
Practice Address - Zip Code:23043
Practice Address - Country:US
Practice Address - Phone:804-776-8000
Practice Address - Fax:804-776-6277
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001205470163W00000X
VA0024167776363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA017488R53Medicare PIN