Provider Demographics
NPI:1629168745
Name:MCAULIFFE, KELLY S (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:MCAULIFFE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15769 WC MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-7327
Mailing Address - Country:US
Mailing Address - Phone:804-419-9760
Mailing Address - Fax:804-378-9140
Practice Address - Street 1:15769 WC MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-7327
Practice Address - Country:US
Practice Address - Phone:804-419-9760
Practice Address - Fax:804-378-9140
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024166669363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05728OtherGROUP PTAN
VAC05727OtherGROUP PTAN
VAC05726OtherGROUP PTAN