Provider Demographics
NPI:1689433351
Name:RAINEY, KELLI GULLEN THOMAS (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:GULLEN THOMAS
Last Name:RAINEY
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 PORTERS MILL LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-1267
Mailing Address - Country:US
Mailing Address - Phone:804-221-1199
Mailing Address - Fax:
Practice Address - Street 1:1407 HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2618
Practice Address - Country:US
Practice Address - Phone:804-794-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024189707363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics