Provider Demographics
NPI:1659300598
Name:PACK, KATHLEEN M (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:PACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11768
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-0168
Mailing Address - Country:US
Mailing Address - Phone:804-330-4000
Mailing Address - Fax:804-213-9783
Practice Address - Street 1:8266 ATLEE RD
Practice Address - Street 2:SUITE 230
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1804
Practice Address - Country:US
Practice Address - Phone:804-730-0792
Practice Address - Fax:804-746-7699
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010257239Medicaid
VAQ17342Medicare UPIN