Provider Demographics
NPI:1598316424
Name:SOUTHAM-GEROW, KIMBERLY A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:SOUTHAM-GEROW
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:SOUTHAM-GEROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-3739
Mailing Address - Country:US
Mailing Address - Phone:804-263-3265
Mailing Address - Fax:
Practice Address - Street 1:2305 N PARHAM RD STE 3
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-3156
Practice Address - Country:US
Practice Address - Phone:804-263-4365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178278363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024178278OtherBOARD OF NURSING