Provider Demographics
NPI:1417678749
Name:WADE, KRISTY A (MSN,APRN,PMHNP)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:A
Last Name:WADE
Suffix:
Gender:F
Credentials:MSN,APRN,PMHNP
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:A
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, APRN, PMHNP-BC
Mailing Address - Street 1:2110 GALLOWS RD STE D
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3962
Mailing Address - Country:US
Mailing Address - Phone:202-670-2828
Mailing Address - Fax:
Practice Address - Street 1:2110 GALLOWS RD STE D
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3962
Practice Address - Country:US
Practice Address - Phone:202-670-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185007363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health