Provider Demographics
NPI:1619429214
Name:ORTWINE, KATHLEEN NUCKOLS
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NUCKOLS
Last Name:ORTWINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7090 COVENANT WOODS DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-7025
Mailing Address - Country:US
Mailing Address - Phone:804-559-8936
Mailing Address - Fax:
Practice Address - Street 1:7090 COVENANT WOODS DR
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-7025
Practice Address - Country:US
Practice Address - Phone:804-559-8936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-30
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604596225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant