Provider Demographics
NPI:1871001420
Name:FORD, KAREN LAVONNE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LAVONNE
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 PORTSMOUTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201
Mailing Address - Country:US
Mailing Address - Phone:276-210-5051
Mailing Address - Fax:
Practice Address - Street 1:727 PORTSMOUTH AVENUE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201
Practice Address - Country:US
Practice Address - Phone:276-210-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0454187013Medicaid