Provider Demographics
NPI:1689727380
Name:TULLY, KATHERINE DENISE (CNNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DENISE
Last Name:TULLY
Suffix:
Gender:F
Credentials:CNNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:BURKE
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 PASTURE LANE
Mailing Address - Street 2:
Mailing Address - City:YORK TOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693
Mailing Address - Country:US
Mailing Address - Phone:757-343-6146
Mailing Address - Fax:
Practice Address - Street 1:1060 1ST COLONIAL RD
Practice Address - Street 2:PEDIATRIX MEDICAL GROUP
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454
Practice Address - Country:US
Practice Address - Phone:757-395-6326
Practice Address - Fax:757-395-6387
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166425363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal