Provider Demographics
NPI:1609994151
Name:DAVIS, KELLY J (RNC,MSNNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RNC,MSNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 POPLAR HILL RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5531
Mailing Address - Country:US
Mailing Address - Phone:757-673-8383
Mailing Address - Fax:757-483-9350
Practice Address - Street 1:3802 POPLAR HILL RD
Practice Address - Street 2:SUITE C
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5531
Practice Address - Country:US
Practice Address - Phone:757-483-4600
Practice Address - Fax:757-483-9350
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167309363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024167309OtherNP LICENSE
VA1609994151Medicaid
VAVAA101448Medicare PIN