Provider Demographics
NPI:1659333847
Name:KENNISON, VIRGINIA O (MSPT, OCS)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:O
Last Name:KENNISON
Suffix:
Gender:F
Credentials:MSPT, OCS
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:J
Other - Last Name:OGREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPT,OCS
Mailing Address - Street 1:5388 DISCOVERY PARK BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-8218
Mailing Address - Country:US
Mailing Address - Phone:757-903-4230
Mailing Address - Fax:757-903-4231
Practice Address - Street 1:5388 DISCOVERY PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-8218
Practice Address - Country:US
Practice Address - Phone:757-903-4230
Practice Address - Fax:757-903-4231
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192973OtherBCBS PHYSICAL THERAPY
VA8928657Medicaid
VA650018759OtherRAILROAD MEDICARE
5583189OtherAETNA
VA650000217Medicare PIN
VA650018759OtherRAILROAD MEDICARE