Provider Demographics
NPI:1609030816
Name:BOTTS, KYLENE E (NP-C)
Entity Type:Individual
Prefix:MS
First Name:KYLENE
Middle Name:E
Last Name:BOTTS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KYLENE
Other - Middle Name:E
Other - Last Name:HAMLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:445 CHARLES H DIMMOCK PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2970
Mailing Address - Country:US
Mailing Address - Phone:804-520-1764
Mailing Address - Fax:866-781-3220
Practice Address - Street 1:445 CHARLES H DIMMOCK PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2970
Practice Address - Country:US
Practice Address - Phone:804-520-1764
Practice Address - Fax:866-781-3220
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024-167902363LF0000X
VA0024167902363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVN394AMedicare PIN