Provider Demographics
NPI:1598901738
Name:ROSE-VALLEJO, KATHRYN ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:ROSE-VALLEJO
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 1:5310 TWIN HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5682
Mailing Address - Country:US
Mailing Address - Phone:804-364-3528
Mailing Address - Fax:
Practice Address - Street 1:5310 TWIN HICKORY RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5682
Practice Address - Country:US
Practice Address - Phone:804-364-3528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057168207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00817415Medicare PIN
VA022712V12Medicare PIN
VA1598901738Medicare PIN
PA070789HYLMedicare PIN
G69078Medicare UPIN